Provider Demographics
NPI:1376996249
Name:OKUBADEJO, MFONOBONG I (MD)
Entity Type:Individual
Prefix:
First Name:MFONOBONG
Middle Name:I
Last Name:OKUBADEJO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5282 MEDICAL DR STE 180
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-5384
Mailing Address - Country:US
Mailing Address - Phone:210-450-9850
Mailing Address - Fax:210-450-6095
Practice Address - Street 1:5282 MEDICAL DR STE 180
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5384
Practice Address - Country:US
Practice Address - Phone:210-450-9850
Practice Address - Fax:210-450-6095
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS9575207L00000X, 207LP2900X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX428794802OtherCSHCN
TX428794801Medicaid