Provider Demographics
NPI:1013022078
Name:OBASIOLU, CHARLES-CHIDI W (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES-CHIDI
Middle Name:W
Last Name:OBASIOLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:147 MILK ST FL 9
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-6540
Mailing Address - Fax:
Practice Address - Street 1:CTR FOR FERTILITY & REPRO HLTH
Practice Address - Street 2:133 BROOKLINE AVE
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215
Practice Address - Country:US
Practice Address - Phone:617-421-2987
Practice Address - Fax:617-421-2989
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA73931207VG0400X, 207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3180468Medicaid
MA3180468Medicaid