Healthcare Provider Details

I. General information

NPI: 1760686109
Provider Name (Legal Business Name): CLETUS O OKONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24800 INTERSTATE 45 SUITE 110
SPRING TX
77386-2344
US

IV. Provider business mailing address

24800 INTERSTATE 45 SUITE 110
SPRING TX
77386-2344
US

V. Phone/Fax

Practice location:
  • Phone: 281-419-9901
  • Fax: 281-419-7551
Mailing address:
  • Phone: 281-419-9901
  • Fax: 281-419-7551

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: