Provider Demographics
NPI:1699193771
Name:OKUGO, GLORY
Entity Type:Individual
Prefix:
First Name:GLORY
Middle Name:
Last Name:OKUGO
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 1:1131 MEADOW CREEK DR.
Mailing Address - Street 2:258
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18780 INTERSTATE 20
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:TX
Practice Address - Zip Code:75103-3593
Practice Address - Country:US
Practice Address - Phone:903-567-7748
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-04
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288233207P00000X
TXS9197207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1M0904OtherMEDICARE