Provider Demographics
NPI:1942439336
Name:JAIYEOBA, CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:JAIYEOBA
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 1:800 8TH AVE STE 306
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2602
Mailing Address - Country:US
Mailing Address - Phone:682-224-3748
Mailing Address - Fax:682-841-0039
Practice Address - Street 1:1866 KELLER PKWY
Practice Address - Street 2:
Practice Address - City:KELLER
Practice Address - State:TX
Practice Address - Zip Code:76248-3764
Practice Address - Country:US
Practice Address - Phone:682-224-3748
Practice Address - Fax:682-841-0039
Is Sole Proprietor?:No
Enumeration Date:2009-07-07
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301094929207RG0100X
TXT9412207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology