Basic Information
| Provider Information | |||||||||
| NPI: | 1417380890 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OGBEIDE | ||||||||
| FirstName: | ENARUNA | ||||||||
| MiddleName: | CHRISTOPHER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 122 W JOHN CARPENTER FWY STE 420 | ||||||||
| Address2: | |||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750392014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729573000 | ||||||||
| FaxNumber: | 9729573005 | ||||||||
| Practice Location | |||||||||
| Address1: | 5402 AIRLINE DR | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770764902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132391572 | ||||||||
| FaxNumber: | 7132391577 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2013 | ||||||||
| LastUpdateDate: | 01/07/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/07/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05843 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MO2898255 | 01 | MD | DEA | OTHER |