Healthcare Provider Details

I. General information

NPI: 1023118809
Provider Name (Legal Business Name): OBIOMA S AGOMUOH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3120 CARPENTER ST SUITE 111
HAMTRAMCK MI
48212-9802
US

IV. Provider business mailing address

27900 BERKSHIRE DR
SOUTHFIELD MI
48076-4957
US

V. Phone/Fax

Practice location:
  • Phone: 313-893-8314
  • Fax: 313-893-7532
Mailing address:
  • Phone: 313-893-8314
  • Fax: 313-893-7532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4030063912
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number4030063912
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: