Healthcare Provider Details

I. General information

NPI: 1275393506
Provider Name (Legal Business Name): OLAYINKA OGUNTODU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2024
Last Update Date: 03/21/2024
Certification Date: 03/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1148 WAGGONER DR
CROSS ROADS TX
76227-4514
US

IV. Provider business mailing address

1148 WAGGONER DR
CROSS ROADS TX
76227-4514
US

V. Phone/Fax

Practice location:
  • Phone: 469-479-7134
  • Fax:
Mailing address:
  • Phone: 469-479-7134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: