Basic Information
| Provider Information | |||||||||
| NPI: | 1366679573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OGUNLADE | ||||||||
| FirstName: | IYABODE | ||||||||
| MiddleName: | MUNIRAT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AGBOOLA | ||||||||
| OtherFirstName: | IYABODE | ||||||||
| OtherMiddleName: | MUNIRAT | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13523 HARGRAVE ROAD | ||||||||
| Address2: | PRISTINE OB-GYN CARE | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812064496 | ||||||||
| FaxNumber: | 2812064487 | ||||||||
| Practice Location | |||||||||
| Address1: | 13523 HARGRAVE ROAD | ||||||||
| Address2: | PRISTINE OB-GYN CARE | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 77070 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812064496 | ||||||||
| FaxNumber: | 2812064487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | M8471 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 207569903 | 05 | TX | MEDICAID |