Healthcare Provider Details

I. General information

NPI: 1043224132
Provider Name (Legal Business Name): MICHAEL EBHOTA OKOGBO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 04/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15210 I-45 S SUITE 110
CONROE TX
77384-4105
US

IV. Provider business mailing address

15210 I-45 SOUTH SUITE 110
CONROE TX
77384-4105
US

V. Phone/Fax

Practice location:
  • Phone: 936-270-8655
  • Fax: 936-270-8739
Mailing address:
  • Phone: 936-270-8655
  • Fax: 936-270-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberK4516
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: