MEDICARE: MARCIA PHEMBA MBADU D.M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	390200000X	Student in an Organized Health Care Education/Training Program	DRPM2049	FL
3	1223P0300X	Periodontics	38777	TX

General Provider Information

NPI Number	:	1225595416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARCIA PHEMBA MBADU D.M.D

Provider Business Mailing Address
First Line	:	3420 MILWAUKEE AVE APT 1701
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79407-3707
Country	:	US
Telephone Number	:	630-901-2819
Fax Number	:

Provider Business Practice Location Address
First Line	:	4415 66TH ST STE 112
Second Line	:
City	:	LUBBOCK
State	:	TX
Zip	:	79414-4811
Country	:	US
Telephone Number	:	903-758-3329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2019
Last Update Date	:	07/26/2023

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