Basic Information
| Provider Information | |||||||||
| NPI: | 1699193771 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OKUGO | ||||||||
| FirstName: | GLORY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1131 MEADOW CREEK DR. | ||||||||
| Address2: | 258 | ||||||||
| City: | IRVING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75038 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 18780 INTERSTATE 20 | ||||||||
| Address2: | |||||||||
| City: | CANTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 751033593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035677748 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2014 | ||||||||
| LastUpdateDate: | 03/18/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 288233 | NY | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | S9197 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1M0904 | 01 | TX | MEDICARE | OTHER |