Healthcare Provider Details

I. General information

NPI: 1306477088
Provider Name (Legal Business Name): DR. OGE JIDEONWO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2020
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7747 KIRBY DR
HOUSTON TX
77030-4309
US

IV. Provider business mailing address

PO BOX 740603
HOUSTON TX
77274-0603
US

V. Phone/Fax

Practice location:
  • Phone: 713-661-7440
  • Fax:
Mailing address:
  • Phone: 713-444-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number45611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: