Provider Demographics
NPI:1003592510
Name:OGUNTODU, OREDUNNI
Entity Type:Individual
Prefix:
First Name:OREDUNNI
Middle Name:
Last Name:OGUNTODU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 WATERFORD GLEN DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-9104
Mailing Address - Country:US
Mailing Address - Phone:214-903-4783
Mailing Address - Fax:
Practice Address - Street 1:109 GARDEN GROVE LN
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-0163
Practice Address - Country:US
Practice Address - Phone:817-323-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-27
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1114727363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health