Provider Demographics
NPI:1346342342
Name:OMOBA, EMMANUEL A (MD)
Entity type:Individual
Prefix:
First Name:EMMANUEL
Middle Name:A
Last Name:OMOBA
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 1:509 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-1645
Mailing Address - Country:US
Mailing Address - Phone:715-615-2078
Mailing Address - Fax:
Practice Address - Street 1:ELM AND CARLTON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14263-0001
Practice Address - Country:US
Practice Address - Phone:716-845-2300
Practice Address - Fax:716-845-3549
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3177822085R0202X
MN631142085R0202X
WI335392085R0202X
IAMD-447722085R0202X
GUM-22062085R0202X
IL0360850892085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32447500Medicaid
F37837Medicare UPIN