Provider Demographics
NPI:1225506421
Name:EDGAL, SIMON OLUBUNMI
Entity Type:Individual
Prefix:
First Name:SIMON
Middle Name:OLUBUNMI
Last Name:EDGAL
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 1:14601 BELLAIRE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77083-2505
Mailing Address - Country:US
Mailing Address - Phone:832-748-4240
Mailing Address - Fax:
Practice Address - Street 1:21739 MANITOU FALLS LN
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77449-4697
Practice Address - Country:US
Practice Address - Phone:832-748-4240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle