Provider Demographics
NPI:1992768378
Name:EGBO, OBINNA P (MD)
Entity type:Individual
Prefix:DR
First Name:OBINNA
Middle Name:P
Last Name:EGBO
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:PO BOX 11773
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85248-0013
Mailing Address - Country:US
Mailing Address - Phone:480-907-7707
Mailing Address - Fax:480-907-7097
Practice Address - Street 1:350 W THOMAS RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4409
Practice Address - Country:US
Practice Address - Phone:602-900-9466
Practice Address - Fax:800-230-9466
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33582207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ33582OtherLICENSE
AZ930190Medicaid
AZZ171269Medicare PIN