Healthcare Provider Details

I. General information

NPI: 1164916391
Provider Name (Legal Business Name): NYAJUOK TER DUP WUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 01/25/2022
Certification Date: 01/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 UNIVERSITY BLVD
GALVESTON TX
77555
US

IV. Provider business mailing address

PO BOX 650859 DEPT 710
DALLAS TX
75265
US

V. Phone/Fax

Practice location:
  • Phone: 281-614-1256
  • Fax: 281-614-1587
Mailing address:
  • Phone: 409-772-2222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberT3412
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: