Provider Demographics
NPI:1164630117
Name:OBEMBE, OLUFOLAJIMI (MD)
Entity Type:Individual
Prefix:
First Name:OLUFOLAJIMI
Middle Name:
Last Name:OBEMBE
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-467-2868
Mailing Address - Fax:
Practice Address - Street 1:79 MADISON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-7802
Practice Address - Country:US
Practice Address - Phone:856-242-7343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAMD490962085B0100X
NE257712085R0202X
KS04-344222085R0202X
VA01012392432085R0202X
ARE-140892085R0202X
AZ413442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200656640BMedicaid
AZP00812940OtherRAILROAD MEDICARE
AZ431219Medicaid
KS110357005Medicare PIN
AZZ129887Medicare PIN