Basic Information
| Provider Information | |||||||||
| NPI: | 1770579492 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBIESIE | ||||||||
| FirstName: | NDIDIAMAKA | ||||||||
| MiddleName: | UZOMA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OKAFOR | ||||||||
| OtherFirstName: | NDIDIAMAKA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 530 E MCDOWELL RD STE 107-609 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850041549 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6027904108 | ||||||||
| FaxNumber: | 6235169319 | ||||||||
| Practice Location | |||||||||
| Address1: | 3330 N 2ND ST STE 401 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122371 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022541136 | ||||||||
| FaxNumber: | 6022791720 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2005 | ||||||||
| LastUpdateDate: | 12/02/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 30584 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RI0200X | 30584 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 763062 | 05 | AZ | MEDICAID |