Healthcare Provider Details

I. General information

NPI: 1740741644
Provider Name (Legal Business Name): OSAMUYI IDUBOR DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2019
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 GLENWOOD DR STE E500
CHATTANOOGA TN
37404-1138
US

IV. Provider business mailing address

PO BOX 80426
CHATTANOOGA TN
37414-7426
US

V. Phone/Fax

Practice location:
  • Phone: 423-495-2635
  • Fax: 423-495-2638
Mailing address:
  • Phone: 423-495-6841
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number6411
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: