Healthcare Provider Details

I. General information

NPI: 1902684061
Provider Name (Legal Business Name): JOHN OSAMUYIMEN ODIASE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2023
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25700 INTERSTATE 45 N STE 440
SPRING TX
77386-1967
US

IV. Provider business mailing address

8919 SQUARE VIEW LN
TOMBALL TX
77375-1679
US

V. Phone/Fax

Practice location:
  • Phone: 281-651-2268
  • Fax: 281-918-4736
Mailing address:
  • Phone: 909-667-6885
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1039109
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: