Healthcare Provider Details

I. General information

NPI: 1972353308
Provider Name (Legal Business Name): PETER JUDE CHUKWUEMEKA OTUGO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 03/26/2024
Certification Date: 03/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8813 TRACY DR
OKLAHOMA CITY OK
73132-1070
US

IV. Provider business mailing address

8813 TRACY DR
OKLAHOMA CITY OK
73132-1070
US

V. Phone/Fax

Practice location:
  • Phone: 405-503-7010
  • Fax:
Mailing address:
  • Phone: 405-503-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: