Provider Demographics
NPI:1124569587
Name:DR IYABO A ELEMUREN-OGUNMUYIWA PA
Entity Type:Organization
Organization Name:DR IYABO A ELEMUREN-OGUNMUYIWA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IYABO
Authorized Official - Middle Name:A
Authorized Official - Last Name:ELEMUREN-OGUNMUYIWA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:254-699-8521
Mailing Address - Street 1:813 S AMY LN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1953
Mailing Address - Country:US
Mailing Address - Phone:254-699-8521
Mailing Address - Fax:254-213-1509
Practice Address - Street 1:813 S AMY LN
Practice Address - Street 2:SUITE 101
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1953
Practice Address - Country:US
Practice Address - Phone:254-699-8521
Practice Address - Fax:254-213-1509
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-17
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty