Provider Demographics
NPI:1962646174
Name:OGBOENYIYA, ACHO JOHNSON
Entity Type:Individual
Prefix:MR
First Name:ACHO
Middle Name:JOHNSON
Last Name:OGBOENYIYA
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 1:10515 SOUTHWEST FWY
Mailing Address - Street 2:SUIT D 103
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-1127
Mailing Address - Country:US
Mailing Address - Phone:713-777-1405
Mailing Address - Fax:713-777-1420
Practice Address - Street 1:10515 SOUTHWEST FWY
Practice Address - Street 2:SUITE D 103
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1127
Practice Address - Country:US
Practice Address - Phone:713-777-1405
Practice Address - Fax:713-777-1420
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1000040332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies