Provider Demographics
NPI:1437109220
Name:COMPLETE FAMILY PRACTICE & SPORTS MEDICINE, PA
Entity Type:Organization
Organization Name:COMPLETE FAMILY PRACTICE & SPORTS MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OBINNA
Authorized Official - Middle Name:U
Authorized Official - Last Name:CHUKWUOCHA
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:214-319-2900
Mailing Address - Street 1:1151 N BUCKNER BLVD
Mailing Address - Street 2:SUITE 405
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75218-3426
Mailing Address - Country:US
Mailing Address - Phone:214-319-2900
Mailing Address - Fax:
Practice Address - Street 1:1151 N BUCKNER BLVD
Practice Address - Street 2:SUITE 405
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75218-3426
Practice Address - Country:US
Practice Address - Phone:214-319-2900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-11
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181705801Medicaid
TX00W590Medicare PIN
TX181705801Medicaid