Basic Information
| Provider Information | |||||||||
| NPI: | 1114918026 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | OSIBAMIRO | ||||||||
| FirstName: | ADEBAMBO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P O BOX 1007 | ||||||||
| Address2: | |||||||||
| City: | MURRIETA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925641007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517193330 | ||||||||
| FaxNumber: | 9512966741 | ||||||||
| Practice Location | |||||||||
| Address1: | 2637 E CARSON ST | ||||||||
| Address2: | |||||||||
| City: | CARSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908101508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108471321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2005 | ||||||||
| LastUpdateDate: | 07/21/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A64972 | CA | N | Allopathic & Osteopathic Physicians | General Practice | 207L00000X | A64972 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A649720 | 05 | CA | MEDICAID |