Basic Information
Provider Information | |||||||||
NPI: | 1639461395 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | UGWU | ||||||||
FirstName: | DANA | ||||||||
MiddleName: | CHANELLE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D., MPH | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROLLERSON | ||||||||
OtherFirstName: | DANA | ||||||||
OtherMiddleName: | CHANELLE | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D., MPH | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 5300 N INDEPENDENCE AVE STE 280 | ||||||||
Address2: |   | ||||||||
City: | OKLAHOMA CITY | ||||||||
State: | OK | ||||||||
PostalCode: | 731125555 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058444300 | ||||||||
FaxNumber: | 4058444366 | ||||||||
Practice Location | |||||||||
Address1: | 1700 RENAISSANCE BLVD | ||||||||
Address2: |   | ||||||||
City: | EDMOND | ||||||||
State: | OK | ||||||||
PostalCode: | 730133022 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4058444300 | ||||||||
FaxNumber: | 4058444366 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2011 | ||||||||
LastUpdateDate: | 04/30/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35536 | OK | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.