Basic Information
| Provider Information | |||||||||
| NPI: | 1285731521 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMBABA | ||||||||
| FirstName: | JACKSON | ||||||||
| MiddleName: | MOSONGO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OMBABA | ||||||||
| OtherFirstName: | JACKSON | ||||||||
| OtherMiddleName: | M. | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9520 | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799959520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155459795 | ||||||||
| FaxNumber: | 9155459799 | ||||||||
| Practice Location | |||||||||
| Address1: | 4801 ALBERTA AVE | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155457507 | ||||||||
| FaxNumber: | 9155459799 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/25/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | 41243 TEMP. | TX | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 207P00000X | M6813 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 208600000X | 41243 TEMPORARY | TX | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 178871301 | 05 | TX | MEDICAID | 178871302 | 01 | TX | CSHCN | OTHER |