Provider Demographics
NPI:1649810219
Name:OSISIOMA, MAXWELL ONYEDIKACHI (SFIDC)
Entity type:Individual
Prefix:
First Name:MAXWELL
Middle Name:ONYEDIKACHI
Last Name:OSISIOMA
Suffix:
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 557 BOX 1724
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96379-0018
Mailing Address - Country:US
Mailing Address - Phone:773-807-2402
Mailing Address - Fax:
Practice Address - Street 1:PSD-18, MACG-18
Practice Address - Street 2:1ST MAW UNIT 37172
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96372
Practice Address - Country:US
Practice Address - Phone:773-807-2402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-13
Last Update Date:2020-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman