Provider Demographics
NPI:1508674599
Name:IGORI, EGHOSA GABRIEL
Entity type:Individual
Prefix:
First Name:EGHOSA
Middle Name:GABRIEL
Last Name:IGORI
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 1:4629 CHAPMAN ST
Mailing Address - Street 2:
Mailing Address - City:THE COLONY
Mailing Address - State:TX
Mailing Address - Zip Code:75056-3107
Mailing Address - Country:US
Mailing Address - Phone:945-268-3192
Mailing Address - Fax:
Practice Address - Street 1:4925 WAMPLER DR
Practice Address - Street 2:
Practice Address - City:THE COLONY
Practice Address - State:TX
Practice Address - Zip Code:75056-1024
Practice Address - Country:US
Practice Address - Phone:469-379-7405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-21
Last Update Date:2024-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156F00000X, 171W00000X, 343900000X, 344600000X, 347C00000X
TX51462457172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Multi-Specialty
No156F00000XEye and Vision Services ProvidersTechnician/Technologist
No171W00000XOther Service ProvidersContractor
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No344600000XTransportation ServicesTaxi
No347C00000XTransportation ServicesPrivate Vehicle