Healthcare Provider Details

I. General information

NPI: 1770981169
Provider Name (Legal Business Name): MARY OGUNDIRAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2014
Last Update Date: 01/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9850 EMMETT F LOWRY EXPY
TEXAS CITY TX
77591-2000
US

IV. Provider business mailing address

13411 MOONLIT LAKE LN APT 502
PEARLAND TX
77584-3734
US

V. Phone/Fax

Practice location:
  • Phone: 409-938-2230
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP126614
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: