Provider Demographics
NPI:1659650091
Name:OSIFESO, CHUKWUMA SOYINKA (MD)
Entity Type:Individual
Prefix:DR
First Name:CHUKWUMA
Middle Name:SOYINKA
Last Name:OSIFESO
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 1:1133 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2130
Mailing Address - Country:US
Mailing Address - Phone:903-595-5486
Mailing Address - Fax:903-595-5128
Practice Address - Street 1:9900 N CENTRAL EXPY STE 215
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-0929
Practice Address - Country:US
Practice Address - Phone:214-396-4950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-16
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-122832207R00000X
OH57.019023207R00000X
TXT3354207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0101323Medicaid
OH0101323Medicaid