Healthcare Provider Details

I. General information

NPI: 1023329638
Provider Name (Legal Business Name): PRINCE C ESIOBU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 TERRACINA BLVD STE 104B
REDLANDS CA
92373-4870
US

IV. Provider business mailing address

PO BOX 27670
ANAHEIM CA
92809-0122
US

V. Phone/Fax

Practice location:
  • Phone: 323-788-2794
  • Fax:
Mailing address:
  • Phone: 909-793-3954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA156386
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA156386
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: