Healthcare Provider Details

I. General information

NPI: 1194176933
Provider Name (Legal Business Name): OLUFEMI OGUNYEMI
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 06/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 COMMUNICATIONS PKWY
PLANO TX
75093-8800
US

IV. Provider business mailing address

236 BRICKNELL LN
COPPELL TX
75019-2597
US

V. Phone/Fax

Practice location:
  • Phone: 214-501-4672
  • Fax:
Mailing address:
  • Phone: 214-223-4753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2082691
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: