Provider Demographics
NPI:1003235243
Name:BALASIRE, OLUWASEYI SEGUN (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUWASEYI
Middle Name:SEGUN
Last Name:BALASIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 CHANEY RD APT 307
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:TN
Mailing Address - Zip Code:37167-2650
Mailing Address - Country:US
Mailing Address - Phone:813-389-8614
Mailing Address - Fax:
Practice Address - Street 1:20103 LAKE CHABOT RD
Practice Address - Street 2:
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5305
Practice Address - Country:US
Practice Address - Phone:510-727-3256
Practice Address - Fax:510-727-3107
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1118626207R00000X
TN56261207R00000X
CAA152926208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1118626OtherAMERICAN BOARD OF INTERNAL MEDICINE
CAA152926OtherSTATE MEDICAL LICENSE
CAA152926OtherSTATE MEDICAL LICENSE