Basic Information
| Provider Information | |||||||||
| NPI: | 1639331317 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EDO-OHONBA | ||||||||
| FirstName: | OSAZE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 EAST BROADWAY | ||||||||
| Address2: | BOX 50 | ||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738158000 | ||||||||
| FaxNumber: | 5738158556 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 EAST BROADWAY | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652015844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738158000 | ||||||||
| FaxNumber: | 5738158556 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2008 | ||||||||
| LastUpdateDate: | 01/09/2019 | ||||||||
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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 | 207R00000X | MT 185563 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 2018019491 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RP1001X | 2018019491 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 208M00000X | 01065638A | IN | N | Allopathic & Osteopathic Physicians | Hospitalist | 207RC0200X | 2018019491 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
ID Information
| ID | Type | State | Issuer | Description | 200908800 | 05 | IN | MEDICAID |