Healthcare Provider Details

I. General information

NPI: 1447213194
Provider Name (Legal Business Name): IBIDUNNI OMOLAYO UKEGBU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 11/07/2025
Certification Date: 11/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3506 21ST ST STE 401
LUBBOCK TX
79410-1200
US

IV. Provider business mailing address

2727 BOLTON BOONE DR STE 103
DESOTO TX
75115-2019
US

V. Phone/Fax

Practice location:
  • Phone: 469-257-3500
  • Fax: 806-723-7137
Mailing address:
  • Phone: 469-257-3500
  • Fax: 469-449-0286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberL3859
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: