Healthcare Provider Details

I. General information

NPI: 1629560982
Provider Name (Legal Business Name): OMAN OQUENDO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 06/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26111 BUTLER SPRINGS CT
KATY TX
77494-6520
US

IV. Provider business mailing address

26111 BUTLER SPRINGS CT
KATY TX
77494-6520
US

V. Phone/Fax

Practice location:
  • Phone: 832-235-9574
  • Fax:
Mailing address:
  • Phone: 832-235-9574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number18-253
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: