Healthcare Provider Details

I. General information

NPI: 1326913906
Provider Name (Legal Business Name): MR. OSAZE IDUMWONYI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2025
Last Update Date: 11/09/2025
Certification Date: 11/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8500 N STEMMONS FWY STE 1090
DALLAS TX
75247-3848
US

IV. Provider business mailing address

PO BOX 667
CEDAR HILL TX
75106-0667
US

V. Phone/Fax

Practice location:
  • Phone: 972-740-6059
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number20140
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: