Provider Demographics
NPI:1326276353
Name:OGBODO, EMMANUEL O (MBA,, PA-C)
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:O
Last Name:OGBODO
Suffix:
Gender:M
Credentials:MBA,, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27216 BARK LN
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-4749
Mailing Address - Country:US
Mailing Address - Phone:323-481-8386
Mailing Address - Fax:
Practice Address - Street 1:229 W 7TH ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4662
Practice Address - Country:US
Practice Address - Phone:951-487-2550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-29
Last Update Date:2009-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19357363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical