Provider Demographics
NPI:1992055271
Name:OBIEJEMBA, OBINNA
Entity type:Individual
Prefix:DR
First Name:OBINNA
Middle Name:
Last Name:OBIEJEMBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 GARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5695
Mailing Address - Country:US
Mailing Address - Phone:410-800-3440
Mailing Address - Fax:
Practice Address - Street 1:4805 GARRISON BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5695
Practice Address - Country:US
Practice Address - Phone:410-800-3440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR174190363LF0000X, 363LP0808X
DCRN1016041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0002097424Medicaid
MD0002097424Medicaid
DC0002097424Medicaid
MD0002097424Medicaid
DC0002097424Medicare PIN
DC0002097424Medicare UPIN
VA0002097424Medicare Oscar/Certification
VA0002097424Medicare NSC
DC0002097424Medicaid
MD0002097424Medicare PIN
VA0002097424Medicare PIN
MD0002097424Medicare Oscar/Certification
DC0002097424Medicare Oscar/Certification
MD0002097424Medicare NSC
DC0002097424Medicare NSC