Provider Demographics
NPI:1104680255
Name:IDOWU, MODUPE OLUWATOYIN
Entity type:Individual
Prefix:
First Name:MODUPE
Middle Name:OLUWATOYIN
Last Name:IDOWU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7305 ASTER DR
Mailing Address - Street 2:
Mailing Address - City:VENUS
Mailing Address - State:TX
Mailing Address - Zip Code:76084-3776
Mailing Address - Country:US
Mailing Address - Phone:130-180-6611
Mailing Address - Fax:
Practice Address - Street 1:7305 ASTER DR
Practice Address - Street 2:
Practice Address - City:VENUS
Practice Address - State:TX
Practice Address - Zip Code:76084-3776
Practice Address - Country:US
Practice Address - Phone:130-180-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-09
Last Update Date:2024-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124176363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health