Healthcare Provider Details

I. General information

NPI: 1912143421
Provider Name (Legal Business Name): BIELOSE CHUKWUNWIKE KONWE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2009
Last Update Date: 04/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5323 HARRY HINES BLVD
DALLAS TX
75390-9175
US

IV. Provider business mailing address

813 SHOREWOOD DR
COPPELL TX
75019-5603
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-5777
  • Fax:
Mailing address:
  • Phone: 651-208-5780
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberN3798
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberN3798
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: