Provider Demographics
NPI:1487187456
Name:NWACHUKWU, OLUWAFISAYOMI (DO)
Entity Type:Individual
Prefix:
First Name:OLUWAFISAYOMI
Middle Name:
Last Name:NWACHUKWU
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54701 FILE NUMBER
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-4701
Mailing Address - Country:US
Mailing Address - Phone:909-651-4300
Mailing Address - Fax:
Practice Address - Street 1:28078 BAXTER RD STE 110A
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1403
Practice Address - Country:US
Practice Address - Phone:951-290-6394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-06
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A16794208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program