Healthcare Provider Details

I. General information

NPI: 1053994012
Provider Name (Legal Business Name): ABIODUN OGBEBOR
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 CALHOUN RD
HOUSTON TX
77204-2610
US

IV. Provider business mailing address

4300 179TH ST
COUNTRY CLUB HILLS IL
60478-4783
US

V. Phone/Fax

Practice location:
  • Phone: 713-743-2255
  • Fax:
Mailing address:
  • Phone: 708-800-3723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: