Provider Demographics
NPI:1073619342
Name:OKEREKE MOSES MADUBUIKE
Entity type:Organization
Organization Name:OKEREKE MOSES MADUBUIKE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:OKEREKE
Authorized Official - Middle Name:MOSES
Authorized Official - Last Name:MADUBUIKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:972-237-9066
Mailing Address - Street 1:2307 OAK LANE
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75051
Mailing Address - Country:US
Mailing Address - Phone:972-237-9066
Mailing Address - Fax:972-237-9056
Practice Address - Street 1:2307 OAK LANE #205
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051
Practice Address - Country:US
Practice Address - Phone:972-237-9066
Practice Address - Fax:972-237-9056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0079619332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178550301Medicaid
TX178550302Medicaid
TX178550302Medicaid
TX5427720001Medicare NSC