Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 1118626 | CA |
N | 111NI0900X | Internist | 1118626 | CA |
N | 207R00000X | Internist | 56261 | TN |
N | 111NI0900X | Internist | 56261 | TN |
NPI | 1003235243 |
---|---|
Provider Name | Dr. Oluwaseyi Segun Balasire |
First Address | Smyrna, TN 37167-2650 |
Second Address | Castro Valley, CA 94546-5305 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/04/2014 |
Last Update Date | 12/07/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1118626 | AMERICAN BOARD OF INTERNAL MEDICINE (01) | CA |
A152926 | STATE MEDICAL LICENSE (01) | CA |
FB8356683 | FEDERAL DEA LICENSE (01) | CA |