Basic Information
| Provider Information | |||||||||
| NPI: | 1073966222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OVIAWE | ||||||||
| FirstName: | OSAZEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1221 E STATE ST | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 611042231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8159721000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5875 N MAJOR DR | ||||||||
| Address2: | |||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777139034 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098922262 | ||||||||
| FaxNumber: | 4098923336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2016 | ||||||||
| LastUpdateDate: | 07/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 125-069698 | IL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | S5458 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.