Provider Demographics
NPI:1780413062
Name:ODUMODU, IJEOMA
Entity type:Individual
Prefix:
First Name:IJEOMA
Middle Name:
Last Name:ODUMODU
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 W GRAND PKWY N STE 150
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-2153
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8588 KATY FWY STE 226A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-1881
Practice Address - Country:US
Practice Address - Phone:713-532-6884
Practice Address - Fax:713-532-5756
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-26
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1143047363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner