Provider Demographics
NPI:1083331540
Name:OGUNBANWO, BISOLA MOSIDAT
Entity Type:Individual
Prefix:DR
First Name:BISOLA
Middle Name:MOSIDAT
Last Name:OGUNBANWO
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 1:4451 W FUQUA ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77045-6205
Mailing Address - Country:US
Mailing Address - Phone:713-433-6447
Mailing Address - Fax:
Practice Address - Street 1:4451 W FUQUA ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77045-6205
Practice Address - Country:US
Practice Address - Phone:713-433-6447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-25
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX56013183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist