Basic Information
Provider Information | |||||||||
NPI: | 1184697070 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OGBONNA | ||||||||
FirstName: | MARTINA | ||||||||
MiddleName: | C | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EKECHUKWU-OGBONNA | ||||||||
OtherFirstName: | MARTINA | ||||||||
OtherMiddleName: | C | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 6550 FANNIN ST | ||||||||
Address2: | SUITE 1101 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134410006 | ||||||||
FaxNumber: | 7137902727 | ||||||||
Practice Location | |||||||||
Address1: | 6550 FANNIN ST | ||||||||
Address2: | SUITE 1101 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770302717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7134410006 | ||||||||
FaxNumber: | 7137902727 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/10/2006 | ||||||||
LastUpdateDate: | 01/04/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 043670 | CT | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208M00000X | 043670 | CT | N |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 207Q00000X | N9927 | TX | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | N9927 | TX | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 288807503 | 05 | TX |   | MEDICAID | 8EE938 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 001436709 | 05 | CT |   | MEDICAID |