Provider Demographics
NPI:1457563322
Name:OKUNDAYE, OSAZUWA JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:OSAZUWA
Middle Name:JOHN
Last Name:OKUNDAYE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:870 E ALTON GLOOR BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78526-3364
Mailing Address - Country:US
Mailing Address - Phone:956-574-9002
Mailing Address - Fax:956-574-0392
Practice Address - Street 1:870 E ALTON GLOOR BLVD STE A
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TX
Practice Address - Zip Code:78526-3364
Practice Address - Country:US
Practice Address - Phone:956-574-9002
Practice Address - Fax:956-575-0392
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3828TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX093448101Medicaid
TX1457563322Medicaid
TX281633201Medicaid