Provider Demographics
NPI:1588431159
Name:UDEAGHA, IREKE
Entity type:Individual
Prefix:
First Name:IREKE
Middle Name:
Last Name:UDEAGHA
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 1:1919 TAYLOR ST STE F
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-3973
Mailing Address - Country:US
Mailing Address - Phone:626-665-6349
Mailing Address - Fax:
Practice Address - Street 1:1919 TAYLOR ST STE F
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77007-3973
Practice Address - Country:US
Practice Address - Phone:626-665-6349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY5196396347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle