Provider Demographics
NPI:1174397988
Name:IHEZIE, COSMAS ONYEDIKA (MD, CSFA)
Entity type:Individual
Prefix:
First Name:COSMAS
Middle Name:ONYEDIKA
Last Name:IHEZIE
Suffix:
Gender:M
Credentials:MD, CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 LAKE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2826
Mailing Address - Country:US
Mailing Address - Phone:469-237-5072
Mailing Address - Fax:
Practice Address - Street 1:UNIVERSITY OF TEXAS HEALTH SCIENCE CENTER AT TYLER
Practice Address - Street 2:11937 U.S. HWY. 271
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75708-4603
Practice Address - Country:US
Practice Address - Phone:903-877-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-13
Last Update Date:2025-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
TX390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant