Provider Demographics
NPI:1982957106
Name:FOMUSO, GAIUS B
Entity type:Individual
Prefix:
First Name:GAIUS
Middle Name:B
Last Name:FOMUSO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LORIENT DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-5572
Mailing Address - Country:US
Mailing Address - Phone:214-256-6648
Mailing Address - Fax:
Practice Address - Street 1:203 LORIENT DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-5572
Practice Address - Country:US
Practice Address - Phone:214-256-6648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-25
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty