Provider Demographics
NPI:1780297259
Name:OYEFESO, NATHANIEL
Entity type:Individual
Prefix:DR
First Name:NATHANIEL
Middle Name:
Last Name:OYEFESO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8726 RANCHO DE TAOS
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-3776
Mailing Address - Country:US
Mailing Address - Phone:832-364-3420
Mailing Address - Fax:
Practice Address - Street 1:9089 FAIR OAKS PKWY
Practice Address - Street 2:
Practice Address - City:BOERNE
Practice Address - State:TX
Practice Address - Zip Code:78015-4646
Practice Address - Country:US
Practice Address - Phone:219-698-9538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-25
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX57691183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist