Provider Demographics
NPI:1073574919
Name:UGBOMA, STELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:STELLA
Middle Name:
Last Name:UGBOMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3015 LEDGESTONE PL NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7066
Mailing Address - Country:US
Mailing Address - Phone:734-945-2653
Mailing Address - Fax:
Practice Address - Street 1:3333 EVERGREEN DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9493
Practice Address - Country:US
Practice Address - Phone:616-364-4200
Practice Address - Fax:616-364-7347
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080748207L00000X
IN01061550A207L00000X
PAMD484164207L00000X
OH35.094099207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4699962Medicaid
MI4699962Medicaid
MIM71590130Medicare PIN
MIH81822Medicare UPIN
MIA26019061Medicare ID - Type Unspecified