Basic Information
| Provider Information | |||||||||
| NPI: | 1225540081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BALOGUN | ||||||||
| FirstName: | DAMILOLA | ||||||||
| MiddleName: | MARY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6501 FANNIN ST STE NC114 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7137987356 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6720 BERTNER AVE | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323552666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2017 | ||||||||
| LastUpdateDate: | 10/11/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 968405 | TX | N | Nursing Service Providers | Registered Nurse | 367500000X | 623027 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 968405 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 367500000X | AP143223 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 367500000X | 05 | NY | MEDICAID |