Provider Demographics
NPI:1942590591
Name:FAWOLE, CHIAGOZIE OLUCHI (MD)
Entity Type:Individual
Prefix:DR
First Name:CHIAGOZIE
Middle Name:OLUCHI
Last Name:FAWOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHIAGOZIE
Other - Middle Name:OLUCHI
Other - Last Name:ONONIWU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:126 SHELBOURNE RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-4531
Mailing Address - Country:US
Mailing Address - Phone:301-651-6252
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST # UH4143
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-4720
Practice Address - Fax:315-464-4905
Is Sole Proprietor?:No
Enumeration Date:2011-04-17
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288171-1207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology