Healthcare Provider Details

I. General information

NPI: 1497331524
Provider Name (Legal Business Name): AYODELE OGUNMOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2021
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W 34TH ST
HOUSTON TX
77018-6206
US

IV. Provider business mailing address

11511 SHADOW CREEK PKWY
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 713-861-3939
  • Fax:
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU3611
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: