Provider Demographics
NPI:1124156286
Name:OMOBUDE, STEPHEN
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:OMOBUDE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3413 DESOTA AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118
Mailing Address - Country:US
Mailing Address - Phone:216-738-1255
Mailing Address - Fax:216-738-1255
Practice Address - Street 1:3413 DESOTA AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44118
Practice Address - Country:US
Practice Address - Phone:216-738-1255
Practice Address - Fax:216-738-1255
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
STNA 400457110205172A00000X, 376J00000X, 376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered172A00000XOther Service ProvidersDriver
Not Answered376J00000XNursing Service Related ProvidersHomemaker
Not Answered376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1807192OtherODMRDD CONTRACT #
OH2564014Medicaid