Provider Demographics
NPI:1073547220
Name:ADE OSIBAMIRO MD INC
Entity Type:Organization
Organization Name:ADE OSIBAMIRO MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ADE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSIBAMIRO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:800-883-7243
Mailing Address - Street 1:P O BOX 1007
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92564-1007
Mailing Address - Country:US
Mailing Address - Phone:951-719-3330
Mailing Address - Fax:951-296-6741
Practice Address - Street 1:2637 E CARSON ST
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90810-1508
Practice Address - Country:US
Practice Address - Phone:310-847-1321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-11
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA64972207L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A649720Medicaid
CAW18157AMedicare PIN
CA00A649720Medicaid
CABK740Medicare PIN