Healthcare Provider Details

I. General information

NPI: 1659650091
Provider Name (Legal Business Name): CHUKWUMA SOYINKA OSIFESO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 07/07/2022
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9900 N CENTRAL EXPY STE 215
DALLAS TX
75231-0929
US

IV. Provider business mailing address

1133 MEDICAL DR
TYLER TX
75701-2130
US

V. Phone/Fax

Practice location:
  • Phone: 214-396-4950
  • Fax:
Mailing address:
  • Phone: 903-595-5486
  • Fax: 903-595-5128

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35-122832
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number57.019023
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberT3354
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: