Healthcare Provider Details

I. General information

NPI: 1205670387
Provider Name (Legal Business Name): OSAMUDIAMEN JOSEPH OBANOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2024
Last Update Date: 06/24/2024
Certification Date: 06/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4218 BRANNON BRANCH CT
FULSHEAR TX
77441-1543
US

IV. Provider business mailing address

2419 FAIRBREEZE DR
KATY TX
77494-5103
US

V. Phone/Fax

Practice location:
  • Phone: 832-392-1786
  • Fax: 832-437-7341
Mailing address:
  • Phone: 832-392-1786
  • Fax: 832-392-1786

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number149759
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: