Provider Demographics
NPI:1326113218
Name:ELEMUREN-OGUNMUYIWA, IYABO A (MD)
Entity Type:Individual
Prefix:DR
First Name:IYABO
Middle Name:A
Last Name:ELEMUREN-OGUNMUYIWA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:IYABO
Other - Middle Name:BOLA
Other - Last Name:ELEMUREN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:813 S AMY LN
Mailing Address - Street 2:STE 101
Mailing Address - City:HARKER HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:76548-1955
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:STE 101
Practice Address - City:HARKER HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:76548-1955
Practice Address - Country:US
Practice Address - Phone:254-699-8521
Practice Address - Fax:254-213-1509
Is Sole Proprietor?:No
Enumeration Date:2006-11-23
Last Update Date:2017-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4050207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX096222702Medicaid
TX096222702Medicaid
TXG88686Medicare UPIN