Provider Demographics
NPI:1881002376
Name:UMOGBAI, CHISOM P (OD)
Entity Type:Individual
Prefix:
First Name:CHISOM
Middle Name:P
Last Name:UMOGBAI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-893-8172
Practice Address - Street 1:7046 E GOLF LINKS RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85730
Practice Address - Country:US
Practice Address - Phone:520-790-0080
Practice Address - Fax:520-790-1191
Is Sole Proprietor?:No
Enumeration Date:2014-07-28
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2411152W00000X
AZOPT-002335152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist