1942439336 NPI number — CHARLES JAIYEOBA MD

Table of content: CHARLES JAIYEOBA MD (NPI 1942439336)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942439336 NPI number — CHARLES JAIYEOBA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JAIYEOBA
Provider First Name:
CHARLES
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942439336
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 8TH AVE STE 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76104-2602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
682-224-3748
Provider Business Mailing Address Fax Number:
682-841-0039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1866 KELLER PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KELLER
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76248-3764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
682-224-3748
Provider Business Practice Location Address Fax Number:
682-841-0039
Provider Enumeration Date:
07/07/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X , with the licence number:  4301094929 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: T9412 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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