Provider Demographics
NPI:1285731521
Name:OMBABA, JACKSON MOSONGO (MD)
Entity type:Individual
Prefix:DR
First Name:JACKSON
Middle Name:MOSONGO
Last Name:OMBABA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACKSON
Other - Middle Name:M
Other - Last Name:OMBABA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-545-9795
Mailing Address - Fax:915-545-9799
Practice Address - Street 1:4801 ALBERTA AVE
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79905
Practice Address - Country:US
Practice Address - Phone:915-545-7507
Practice Address - Fax:915-545-9799
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX41243 TEMP.2086S0102X
TXM6813207P00000X
TX41243 TEMPORARY208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX178871301Medicaid
TX178871302OtherCSHCN