Provider Demographics
NPI:1003965153
Name:OBIEKWE, SAMUEL R (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:R
Last Name:OBIEKWE
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 1:113 W G ST # 315
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6096
Mailing Address - Country:US
Mailing Address - Phone:909-816-1032
Mailing Address - Fax:
Practice Address - Street 1:113 W G ST # 315
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6096
Practice Address - Country:US
Practice Address - Phone:909-816-1032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC51428208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C514280Medicaid
CAWC51428AMedicare ID - Type Unspecified
CAE77117Medicare UPIN