Basic Information
| Provider Information | |||||||||
| NPI: | 1659650091 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSIFESO | ||||||||
| FirstName: | CHUKWUMA | ||||||||
| MiddleName: | SOYINKA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1133 MEDICAL DR | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757012130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035955486 | ||||||||
| FaxNumber: | 9035955128 | ||||||||
| Practice Location | |||||||||
| Address1: | 9900 N CENTRAL EXPY STE 215 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752310929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143964950 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/16/2011 | ||||||||
| LastUpdateDate: | 07/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35-122832 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 57.019023 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RN0300X | T3354 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 0101323 | 05 | OH | MEDICAID |