Healthcare Provider Details

I. General information

NPI: 1467680173
Provider Name (Legal Business Name): OBIOMA OGBONNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 RIVERPLACE BLVD SUITE 620
JACKSONVILLE FL
32207-9046
US

IV. Provider business mailing address

1200 RIVERPLACE BLVD SUITE 620
JACKSONVILLE FL
32207-9046
US

V. Phone/Fax

Practice location:
  • Phone: 904-396-6620
  • Fax: 904-396-6528
Mailing address:
  • Phone: 904-396-6620
  • Fax: 904-396-6528

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number53754
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number66040
License Number StateMN
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24086
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME113771
License Number StateFL
# 5
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR8446
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: