Healthcare Provider Details

I. General information

NPI: 1063884625
Provider Name (Legal Business Name): MR. ANTHONY OGBODO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2471 NORTH NAGLEE ROAD SUITE 100 #1037
TRACY CA
95304-3519
US

IV. Provider business mailing address

2471 NORTH NAGLEE ROAD SUITE 100 #1037
TRACY CA
95304-3519
US

V. Phone/Fax

Practice location:
  • Phone: 510-755-3004
  • Fax:
Mailing address:
  • Phone: 510-755-3004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002864
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: