Healthcare Provider Details

I. General information

NPI: 1346467370
Provider Name (Legal Business Name): BENNET IFEAKANDU OMALU M.D., M.B.A., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2007
Last Update Date: 03/23/2020
Certification Date: 03/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 V STREET UNIVERSITY OF CALIFORNIA, DAVIS, MEDICAL CENTER
SACRAMENTO CA
95817
US

IV. Provider business mailing address

3031 W MARCH LN STE 323
STOCKTON CA
95219-6578
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2525
  • Fax: 866-402-6875
Mailing address:
  • Phone: 92-636-2822
  • Fax: 866-402-6875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberC52868
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberC52868
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberC52868
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC52868
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code209800000X
TaxonomyLegal Medicine (M.D./D.O.) Physician
License NumberC52868
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207ZC0006X
TaxonomyClinical Pathology Physician
License NumberC52868
License Number StateCA
# 7
Primary TaxonomyY
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License NumberC52868
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: