Provider Demographics
NPI:1215999107
Name:MBEBOH, BERNARD ASONGANYI (MD)
Entity type:Individual
Prefix:DR
First Name:BERNARD
Middle Name:ASONGANYI
Last Name:MBEBOH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3031 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3046
Mailing Address - Country:US
Mailing Address - Phone:313-871-3751
Mailing Address - Fax:
Practice Address - Street 1:3031 W GRAND BLVD STE 600
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3014
Practice Address - Country:US
Practice Address - Phone:313-871-3751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03163363A00000X
MDD0099241207R00000X
MI4351048812390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine