Healthcare Provider Details

I. General information

NPI: 1477933356
Provider Name (Legal Business Name): ESAYAS OKUBAMICHAEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 03/29/2023
Certification Date: 03/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE N
SAINT CLOUD MN
56303
US

IV. Provider business mailing address

1200 6TH AVE N
SAINT CLOUD MN
56303-2736
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-5131
  • Fax: 320-255-5973
Mailing address:
  • Phone: 320-252-5131
  • Fax: 320-255-5973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number63039
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: