Healthcare Provider Details

I. General information

NPI: 1407811854
Provider Name (Legal Business Name): MICHAEL K OBENG MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2006
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 N ROXBURY DR STE 205 MIKO PLASTIC SURGERY
BEVERLY HILLS CA
90210-5004
US

IV. Provider business mailing address

435 N ROXBURY DRIVE SUITE 205 MIKO PLASTIC SURGERY
BEVERLY HILLS CA
90210
US

V. Phone/Fax

Practice location:
  • Phone: 310-275-2705
  • Fax: 310-275-2701
Mailing address:
  • Phone: 310-275-2705
  • Fax: 310-275-2701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA107087
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number35.088914
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: