Provider Demographics
NPI:1043224132
Name:OKOGBO, MICHAEL EBHOTA (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:EBHOTA
Last Name:OKOGBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15210 I-45 SOUTH
Mailing Address - Street 2:SUITE 110
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-4105
Mailing Address - Country:US
Mailing Address - Phone:936-270-8655
Mailing Address - Fax:936-270-8739
Practice Address - Street 1:15210 I-45 S
Practice Address - Street 2:SUITE 110
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-4105
Practice Address - Country:US
Practice Address - Phone:936-270-8655
Practice Address - Fax:936-270-8739
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2017-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4516208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125748707Medicaid
OK200134400 AMedicaid
TX125748708OtherCSHCN
NM67022383Medicaid
TX125748707Medicaid
TX8K3086Medicare PIN