Healthcare Provider Details

I. General information

NPI: 1497229694
Provider Name (Legal Business Name): HABEEB AYODEJI OGUNGBADE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2019
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 W WALKER ST
LEAGUE CITY TX
77573-6812
US

IV. Provider business mailing address

2620 W WALKER ST
LEAGUE CITY TX
77573-6812
US

V. Phone/Fax

Practice location:
  • Phone: 281-309-5400
  • Fax:
Mailing address:
  • Phone: 281-309-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2136081
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: