Healthcare Provider Details

I. General information

NPI: 1578703179
Provider Name (Legal Business Name): OBONORUMA I EKHAESE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2009
Last Update Date: 05/08/2024
Certification Date: 05/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10907 MEMORIAL HERMANN DR STE 440
PEARLAND TX
77584-4114
US

IV. Provider business mailing address

PO BOX 891392
HOUSTON TX
77289-1392
US

V. Phone/Fax

Practice location:
  • Phone: 832-915-8140
  • Fax:
Mailing address:
  • Phone: 832-915-8140
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberM9994
License Number StateTX

VIII. Authorized Official

Name: OBONORUMA IMARIABE EKHAESE
Title or Position: PRESIDENT
Credential: D.O
Phone: 713-562-2691