Provider Demographics
NPI:1497950844
Name:OBASUYI-OGUNTULA, VICTORIA
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:
Last Name:OBASUYI-OGUNTULA
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 1:2060 N COLLINS BLVD
Mailing Address - Street 2:SUITE 118
Mailing Address - City:RICHARDSON
Mailing Address - State:TX
Mailing Address - Zip Code:75080-2657
Mailing Address - Country:US
Mailing Address - Phone:214-454-6086
Mailing Address - Fax:
Practice Address - Street 1:2060 N COLLINS BLVD
Practice Address - Street 2:SUITE 118
Practice Address - City:RICHARDSON
Practice Address - State:TX
Practice Address - Zip Code:75080-2657
Practice Address - Country:US
Practice Address - Phone:214-454-6086
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0095992332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies