Provider Demographics
NPI:1427119981
Name:UBUNAMA, INNOCENT N (DO)
Entity type:Individual
Prefix:MR
First Name:INNOCENT
Middle Name:N
Last Name:UBUNAMA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 ORCHARD CENTER DR
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528
Mailing Address - Country:US
Mailing Address - Phone:419-866-2000
Mailing Address - Fax:419-866-2010
Practice Address - Street 1:7100 ORCHARD CENTER DR
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528
Practice Address - Country:US
Practice Address - Phone:419-866-2000
Practice Address - Fax:419-866-2010
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340082532085R0204X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34008253OtherLICENSE
OH2473783Medicaid
OHI06204Medicare UPIN