Provider Demographics
NPI:1073831749
Name:MOMAH, TOBE SAMUEL (MD)
Entity Type:Individual
Prefix:DR
First Name:TOBE
Middle Name:SAMUEL
Last Name:MOMAH
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 7495
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71211-7495
Mailing Address - Country:US
Mailing Address - Phone:318-388-1250
Mailing Address - Fax:318-388-0948
Practice Address - Street 1:2913 DESIARD ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7207
Practice Address - Country:US
Practice Address - Phone:318-651-9914
Practice Address - Fax:318-388-0948
Is Sole Proprietor?:No
Enumeration Date:2010-05-05
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01067928A207Q00000X
LA203851207Q00000X
MS24745207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05458767Medicaid
LA2120328Medicaid
MS552567YJ5DMedicare PIN
LA321446YV77Medicare PIN