Provider Demographics
NPI:1316415565
Name:OSUDE, IFEANYI H (DPT)
Entity type:Individual
Prefix:DR
First Name:IFEANYI
Middle Name:H
Last Name:OSUDE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:IFEANYI
Other - Middle Name:H
Other - Last Name:OSUDE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PT
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3003 W GOOD HOPE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-2042
Practice Address - Country:US
Practice Address - Phone:414-247-4772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14480-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI14480Medicaid