Provider Demographics
NPI:1366265811
Name:OGUNMODEDE, MESHACH B
Entity type:Individual
Prefix:
First Name:MESHACH
Middle Name:B
Last Name:OGUNMODEDE
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 1:2841 BELLFLOWER DR
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-4002
Mailing Address - Country:US
Mailing Address - Phone:214-304-5919
Mailing Address - Fax:
Practice Address - Street 1:2841 BELLFLOWER DR
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-4002
Practice Address - Country:US
Practice Address - Phone:214-304-5919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251X00000XAgenciesSupports Brokerage