Healthcare Provider Details

I. General information

NPI: 1154366946
Provider Name (Legal Business Name): UDOH O OBIOHA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 04/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

980 N D ST
SAN BERNARDINO CA
92410
US

IV. Provider business mailing address

201 S BROADWAY
SANTA ANA CA
92701-5633
US

V. Phone/Fax

Practice location:
  • Phone: 909-521-7509
  • Fax: 909-521-7442
Mailing address:
  • Phone: 509-833-8330
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA42739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: