Healthcare Provider Details

I. General information

NPI: 1053820092
Provider Name (Legal Business Name): OLUMUYIWA MICHAEL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2017
Last Update Date: 09/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E ARAPAHO RD STE 505
RICHARDSON TX
75081-2765
US

IV. Provider business mailing address

18250 MARSH LN APT 1516
DALLAS TX
75287-5710
US

V. Phone/Fax

Practice location:
  • Phone: 972-201-7204
  • Fax:
Mailing address:
  • Phone: 972-201-7204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: