Healthcare Provider Details

I. General information

NPI: 1831305143
Provider Name (Legal Business Name): OGHENESUME DAVID UMUGBE M.D.,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2007
Last Update Date: 05/13/2025
Certification Date: 05/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11175 AZUSA CT STE 110
RANCHO CUCAMONGA CA
91730-4933
US

IV. Provider business mailing address

PO BOX 1328
RANCHO CUCAMONGA CA
91729-1328
US

V. Phone/Fax

Practice location:
  • Phone: 903-617-5098
  • Fax:
Mailing address:
  • Phone: 909-329-5010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberA94047
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA94047
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: