Provider Demographics
NPI:1255698619
Name:IZEIYAMU, OSAYANDE STEPHEN (MD)
Entity type:Individual
Prefix:DR
First Name:OSAYANDE
Middle Name:STEPHEN
Last Name:IZEIYAMU
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 1:194 SW WALL TER
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5086
Mailing Address - Country:US
Mailing Address - Phone:386-719-9227
Mailing Address - Fax:386-719-9488
Practice Address - Street 1:194 SW WALL TER
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5086
Practice Address - Country:US
Practice Address - Phone:386-719-9227
Practice Address - Fax:386-719-9488
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-23
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10043366207Q00000X
FLACN634208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014632400Medicaid