Healthcare Provider Details

I. General information

NPI: 1285792218
Provider Name (Legal Business Name): LINUS C OHAEBOSIM DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 06/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2810 E 21ST ST
WICHITA KS
67214-2252
US

IV. Provider business mailing address

2810 E 21ST ST
WICHITA KS
67214-2252
US

V. Phone/Fax

Practice location:
  • Phone: 316-681-1901
  • Fax: 316-681-1901
Mailing address:
  • Phone: 316-681-1901
  • Fax: 316-618-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05-16911
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: