Healthcare Provider Details

I. General information

NPI: 1477016228
Provider Name (Legal Business Name): MIRIAN CHIBUZO OKOYE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2019
Last Update Date: 10/02/2025
Certification Date: 10/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1601 E DEBBIE LN STE 2109
MANSFIELD TX
76063-4130
US

IV. Provider business mailing address

1601 E DEBBIE LN
MANSFIELD TX
76063-3674
US

V. Phone/Fax

Practice location:
  • Phone: 817-473-9125
  • Fax: 817-473-9126
Mailing address:
  • Phone: 972-792-7300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberU4888
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberU4888
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: