MEDICARE: YIMI OMOFUMA M.A, PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	103T00000X	Psychologist

General Provider Information

NPI Number	:	1497208045
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	YIMI OMOFUMA M.A, PHD

Provider Business Mailing Address
First Line	:	2161 NW MILITARY HWY STE 207
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1844
Country	:	US
Telephone Number	:	210-447-6363
Fax Number	:

Provider Business Practice Location Address
First Line	:	2161 NW MILITARY HWY STE 207
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1844
Country	:	US
Telephone Number	:	210-447-6363
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2016
Last Update Date	:	08/20/2019

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