Provider Demographics
NPI:1205209574
Name:OMENUKOR, UDOKA
Entity Type:Individual
Prefix:
First Name:UDOKA
Middle Name:
Last Name:OMENUKOR
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 1:1675 REPUBLIC PKWY
Mailing Address - Street 2:#200-A
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6903
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 REPUBLIC PKWY
Practice Address - Street 2:#200-A
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6903
Practice Address - Country:US
Practice Address - Phone:214-315-3263
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-08
Last Update Date:2015-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83894133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered