Healthcare Provider Details

I. General information

NPI: 1669928883
Provider Name (Legal Business Name): NORTHSIDE PEDIATRICS ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2016
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 936-270-8655
  • Fax:
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: DR. MICHAEL E OKOGBO
Title or Position: OWNER
Credential: M.D.
Phone: 806-626-3808