Healthcare Provider Details

I. General information

NPI: 1053521583
Provider Name (Legal Business Name): OKECHUKWU ERNEST OBUA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 NAAMANS RD
CLAYMONT DE
19703-2308
US

IV. Provider business mailing address

13902 LITTLE CT
HOUSTON TX
77077-1958
US

V. Phone/Fax

Practice location:
  • Phone: 833-886-2277
  • Fax:
Mailing address:
  • Phone: 214-621-4604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberP0920
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberC1-0011566
License Number StateDE
# 3
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberMD438370
License Number StatePA
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0011566
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: