Healthcare Provider Details

I. General information

NPI: 1356786651
Provider Name (Legal Business Name): EYITEMI OGHOGHO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2013
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 TAUB LOOP
HOUSTON TX
77030-1608
US

IV. Provider business mailing address

1504 TAUB LOOP
HOUSTON TX
77030-1608
US

V. Phone/Fax

Practice location:
  • Phone: 713-873-7045
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberBP10046567
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number036167940
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD53052
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: