Healthcare Provider Details

I. General information

NPI: 1740848431
Provider Name (Legal Business Name): JIDEOFOR UZOMA OGBONNA NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1102 SOLON PLACE WAY STE A
WAXAHACHIE TX
75165-5038
US

IV. Provider business mailing address

2513 EDGEFIELD TRL
MANSFIELD TX
76063-3738
US

V. Phone/Fax

Practice location:
  • Phone: 972-351-9993
  • Fax:
Mailing address:
  • Phone: 469-658-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF03190027
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: