Healthcare Provider Details

I. General information

NPI: 1699193771
Provider Name (Legal Business Name): GLORY OKUGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2014
Last Update Date: 03/18/2021
Certification Date: 03/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18780 INTERSTATE 20
CANTON TX
75103-3593
US

IV. Provider business mailing address

1131 MEADOW CREEK DR. 258
IRVING TX
75038
US

V. Phone/Fax

Practice location:
  • Phone: 903-567-7748
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number288233
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberS9197
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: