Healthcare Provider Details

I. General information

NPI: 1013022078
Provider Name (Legal Business Name): CHARLES-CHIDI W OBASIOLU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CTR FOR FERTILITY & REPRO HLTH 133 BROOKLINE AVE
BOSTON MA
02215
US

IV. Provider business mailing address

147 MILK ST FL 9 PROVIDER ENROLLMENT
BOSTON MA
02109-4806
US

V. Phone/Fax

Practice location:
  • Phone: 617-421-2987
  • Fax: 617-421-2989
Mailing address:
  • Phone: 617-421-6540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number73931
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number73931
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: