Provider Demographics
NPI:1396783056
Name:ENNAMURI, KUMAR B (MD)
Entity type:Individual
Prefix:
First Name:KUMAR
Middle Name:B
Last Name:ENNAMURI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 N PORTER AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6443
Mailing Address - Country:US
Mailing Address - Phone:405-364-0630
Mailing Address - Fax:
Practice Address - Street 1:1125 N PORTER AVE STE 300
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6443
Practice Address - Country:US
Practice Address - Phone:405-364-0630
Practice Address - Fax:405-506-3046
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK20474207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100018370FMedicaid
OK$$$$$$$$$WMedicare PIN
OKG68975Medicare UPIN
OK100018370FMedicaid