Basic Information
| Provider Information | |||||||||
| NPI: | 1295791275 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALUSIMBI | ||||||||
| FirstName: | MBAGA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 UNIVERSITY BLVD | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454350001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372457100 | ||||||||
| FaxNumber: | 9372457999 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 EAST APPLE STREET | ||||||||
| Address2: | SUITE 5253 | ||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372082552 | ||||||||
| FaxNumber: | 9372086154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2006 | ||||||||
| LastUpdateDate: | 06/19/2018 | ||||||||
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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 | 2086S0127X | 35.084491 | OH | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 208600000X | 35084491 | OH | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 2483594 | 05 | OH | MEDICAID |