Provider Demographics
NPI:1346467370
Name:OMALU, BENNET IFEAKANDU (MD, MBA, MPH)
Entity Type:Individual
Prefix:DR
First Name:BENNET
Middle Name:IFEAKANDU
Last Name:OMALU
Suffix:
Gender:M
Credentials:MD, MBA, MPH
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Mailing Address - Street 1:3031 W MARCH LN STE 323
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-6578
Mailing Address - Country:US
Mailing Address - Phone:092-636-2822
Mailing Address - Fax:866-402-6875
Practice Address - Street 1:4400 V STREET
Practice Address - Street 2:UNIVERSITY OF CALIFORNIA, DAVIS, MEDICAL CENTER
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817
Practice Address - Country:US
Practice Address - Phone:916-734-2525
Practice Address - Fax:866-402-6875
Is Sole Proprietor?:No
Enumeration Date:2007-04-19
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC52868207ZC0006X, 207ZF0201X, 207ZN0500X, 207ZP0101X, 207ZP0102X, 209800000X, 202C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical Examiner
No207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology
No207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology
No207ZN0500XAllopathic & Osteopathic PhysiciansPathologyNeuropathology
No207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No209800000XAllopathic & Osteopathic PhysiciansLegal Medicine