Provider Demographics
NPI:1275633786
Name:UDEAGBALA, BENEDICTA OLAMIDE (DO)
Entity Type:Individual
Prefix:
First Name:BENEDICTA
Middle Name:OLAMIDE
Last Name:UDEAGBALA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1395 NW 167TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33169-5710
Mailing Address - Country:US
Mailing Address - Phone:941-357-7950
Mailing Address - Fax:
Practice Address - Street 1:1505 53RD AVE E
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34203-4249
Practice Address - Country:US
Practice Address - Phone:941-357-7950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006079207Q00000X
FLOS17771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0241812Medicaid
OHG36593Medicare UPIN
OH0241812Medicaid
OH0241812Medicaid