Healthcare Provider Details

I. General information

NPI: 1326276353
Provider Name (Legal Business Name): EMMANUEL O OGBODO MBA,, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2009
Last Update Date: 06/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 W 7TH ST
SAN JACINTO CA
92583-4662
US

IV. Provider business mailing address

27216 BARK LN
MORENO VALLEY CA
92555-4749
US

V. Phone/Fax

Practice location:
  • Phone: 951-487-2550
  • Fax:
Mailing address:
  • Phone: 323-481-8386
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA19357
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: