Healthcare Provider Details

I. General information

NPI: 1376046110
Provider Name (Legal Business Name): MODUPE OLUBUKOLA OLOJO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2018
Last Update Date: 03/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 CRYSTAL LAKE DR
DESOTO TX
75115-3798
US

IV. Provider business mailing address

309 CRYSTAL LAKE DR
DESOTO TX
75115-3798
US

V. Phone/Fax

Practice location:
  • Phone: 372-343-8618
  • Fax:
Mailing address:
  • Phone: 372-343-8618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number801826
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: