Healthcare Provider Details

I. General information

NPI: 1932879962
Provider Name (Legal Business Name): DR. UDOCHUKWU CALEB OGU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 S BROADWAY AVE
TYLER TX
75701-4260
US

IV. Provider business mailing address

1620 S BROADWAY AVE
TYLER TX
75701-4260
US

V. Phone/Fax

Practice location:
  • Phone: 903-533-0367
  • Fax:
Mailing address:
  • Phone: 903-533-0367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number689333
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: