Healthcare Provider Details

I. General information

NPI: 1891635280
Provider Name (Legal Business Name): PETER EJIOFOR UGWOKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 OAK GROVE RD
POPLAR BLUFF MO
63901-1573
US

IV. Provider business mailing address

5307 PARADISE COVE LN
KATY TX
77493-8158
US

V. Phone/Fax

Practice location:
  • Phone: 573-776-2000
  • Fax: 573-776-9086
Mailing address:
  • Phone: 573-776-9493
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberTEMPORARY
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: