Provider Demographics
NPI:1114613742
Name:UGOH, GREGORY ANTHONY
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:ANTHONY
Last Name:UGOH
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 1:1501 RED RIVER ST FL 2
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78712-1845
Mailing Address - Country:US
Mailing Address - Phone:832-453-2143
Mailing Address - Fax:
Practice Address - Street 1:1501 RED RIVER ST FL 2
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78712-1845
Practice Address - Country:US
Practice Address - Phone:832-453-2143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-17
Last Update Date:2023-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10083891390200000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207N00000XAllopathic & Osteopathic PhysiciansDermatology