Healthcare Provider Details

I. General information

NPI: 1376996249
Provider Name (Legal Business Name): MFONOBONG I OKUBADEJO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2016
Last Update Date: 03/09/2022
Certification Date: 03/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5282 MEDICAL DR STE 180
SAN ANTONIO TX
78229-5384
US

IV. Provider business mailing address

5282 MEDICAL DR STE 180
SAN ANTONIO TX
78229-5384
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-9850
  • Fax: 210-450-6095
Mailing address:
  • Phone: 210-450-9850
  • Fax: 210-450-6095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberS9575
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberS9575
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: