Provider Demographics
NPI:1972502862
Name:OGBONNAYA, GABRIEL U (MD)
Entity type:Individual
Prefix:
First Name:GABRIEL
Middle Name:U
Last Name:OGBONNAYA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2919 S ELLSWORTH RD
Mailing Address - Street 2:SUITE # 124
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-2164
Mailing Address - Country:US
Mailing Address - Phone:480-361-3636
Mailing Address - Fax:480-361-2525
Practice Address - Street 1:2919 S ELLSWORTH RD
Practice Address - Street 2:SUITE # 124
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85212-2164
Practice Address - Country:US
Practice Address - Phone:480-361-3636
Practice Address - Fax:480-361-2525
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ32142207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ818510Medicaid
AZ109853Medicare PIN
AZ818510Medicaid