Healthcare Provider Details

I. General information

NPI: 1003965153
Provider Name (Legal Business Name): SAMUEL R OBIEKWE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 08/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 W G ST # 315
SAN DIEGO CA
92101-6096
US

IV. Provider business mailing address

113 W G ST # 315
SAN DIEGO CA
92101-6096
US

V. Phone/Fax

Practice location:
  • Phone: 909-816-1032
  • Fax:
Mailing address:
  • Phone: 909-816-1032
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberC51428
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: