Provider Demographics
NPI:1912061276
Name:IDJAGBORO HEALTHCARE AND MEDICAL SERVICES INC
Entity Type:Organization
Organization Name:IDJAGBORO HEALTHCARE AND MEDICAL SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAMIAN
Authorized Official - Middle Name:OKPAKO
Authorized Official - Last Name:IDJAGBORO
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:956-536-1403
Mailing Address - Street 1:9999 W MONTGOMERY RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77088-3100
Mailing Address - Country:US
Mailing Address - Phone:832-598-2571
Mailing Address - Fax:832-598-2572
Practice Address - Street 1:9999 W MONTGOMERY RD
Practice Address - Street 2:SUITE B
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77088-3100
Practice Address - Country:US
Practice Address - Phone:832-598-2571
Practice Address - Fax:832-598-2572
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2009-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03357261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care