Provider Demographics
NPI:1477821106
Name:OLUMESE, THEOPHILUS O (MD)
Entity Type:Individual
Prefix:
First Name:THEOPHILUS
Middle Name:O
Last Name:OLUMESE
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 1:3420 22ND PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79410-1314
Mailing Address - Country:US
Mailing Address - Phone:806-725-5844
Mailing Address - Fax:806-723-6532
Practice Address - Street 1:3506 21ST ST
Practice Address - Street 2:SUITE 605
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79410-1212
Practice Address - Country:US
Practice Address - Phone:806-725-4130
Practice Address - Fax:806-723-7137
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXP3948208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program