Provider Demographics
NPI:1043702467
Name:ODIMEGWU, NDUBUISI DAVID (AGNP-C)
Entity Type:Individual
Prefix:
First Name:NDUBUISI
Middle Name:DAVID
Last Name:ODIMEGWU
Suffix:
Gender:M
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1934 PLUM CREEK LN
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77489-4165
Mailing Address - Country:US
Mailing Address - Phone:651-353-9736
Mailing Address - Fax:
Practice Address - Street 1:5530 W RIDGECREEK DR STE 250
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77053-3536
Practice Address - Country:US
Practice Address - Phone:346-223-2195
Practice Address - Fax:346-998-1550
Is Sole Proprietor?:No
Enumeration Date:2018-06-01
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP137648363LA2200X, 363LP2300X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care