Healthcare Provider Details

I. General information

NPI: 1205246931
Provider Name (Legal Business Name): MS. JEOMI MADUKA OKWARA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 09/16/2020
Certification Date: 09/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC CARDIOVASCULAR MEDICINE 1 UNIVERSITY OF 6201 HARRY HINES BLVD
DALLAS TX
75235-5202
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-7208
US

V. Phone/Fax

Practice location:
  • Phone: 214-633-5555
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberS7522
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number17210208
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number17210208
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: