Provider Demographics
NPI:1033514666
Name:EGO-OSUALA, OBINNA (MD)
Entity Type:Individual
Prefix:
First Name:OBINNA
Middle Name:
Last Name:EGO-OSUALA
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 1:5305 KENILWORTH AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RIVERDALE
Mailing Address - State:MD
Mailing Address - Zip Code:20737
Mailing Address - Country:US
Mailing Address - Phone:301-277-7110
Mailing Address - Fax:
Practice Address - Street 1:5305 KENILWORTH AVE
Practice Address - Street 2:100
Practice Address - City:RIVERDALE
Practice Address - State:MD
Practice Address - Zip Code:20737
Practice Address - Country:US
Practice Address - Phone:301-277-7110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD81089208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics