Provider Demographics
NPI:1053820092
Name:MICHAEL, OLUMUYIWA
Entity Type:Individual
Prefix:
First Name:OLUMUYIWA
Middle Name:
Last Name:MICHAEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18250 MARSH LN APT 1516
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75287-5710
Mailing Address - Country:US
Mailing Address - Phone:972-201-7204
Mailing Address - Fax:
Practice Address - Street 1:500 E ARAPAHO RD STE 505
Practice Address - Street 2:
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75081-2765
Practice Address - Country:US
Practice Address - Phone:972-201-7204
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-21
Last Update Date:2017-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver