Healthcare Provider Details

I. General information

NPI: 1174291926
Provider Name (Legal Business Name): OLUWATOYOSI OLUMIDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2021
Last Update Date: 09/04/2021
Certification Date: 09/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2201 ARBOR ST
HOUSTON TX
77004-6026
US

IV. Provider business mailing address

11355 RICHMOND AVE APT 1721
HOUSTON TX
77082-7662
US

V. Phone/Fax

Practice location:
  • Phone: 833-430-4807
  • Fax:
Mailing address:
  • Phone: 512-785-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083B0002X
TaxonomyObesity Medicine (Preventive Medicine) Physician
License Number1050077
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1050077
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: