Healthcare Provider Details

I. General information

NPI: 1275710758
Provider Name (Legal Business Name): KEMKA S OGBURIA JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2008
Last Update Date: 08/18/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W STATE ROAD 434 SUITE 210
LONGWOOD FL
32750-4981
US

IV. Provider business mailing address

515 W STATE ROAD 434 SUITE 210
LONGWOOD FL
32750-4981
US

V. Phone/Fax

Practice location:
  • Phone: 407-332-8080
  • Fax: 407-260-0602
Mailing address:
  • Phone: 407-332-8080
  • Fax: 407-260-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME101561
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number036118526
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberME101561
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: