Provider Demographics
NPI:1417266024
Name:OMBOGO, ANTHONY ADEN (MD)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:ADEN
Last Name:OMBOGO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:ANTHONY
Other - Middle Name:OBIERO
Other - Last Name:OMBOGO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:303 N CLYDE MORRIS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2709
Mailing Address - Country:US
Mailing Address - Phone:386-756-7748
Mailing Address - Fax:386-761-5449
Practice Address - Street 1:3911 S NOVA RD
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4910
Practice Address - Country:US
Practice Address - Phone:386-756-7748
Practice Address - Fax:386-761-5449
Is Sole Proprietor?:No
Enumeration Date:2010-09-30
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTRN12964207Q00000X
GA66728207Q00000X
FLME108702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112054AMedicaid
GA202I085839Medicare PIN
GA111889Medicare Oscar/Certification
GA111887Medicare Oscar/Certification
GA111904Medicare Oscar/Certification
GA111921Medicare Oscar/Certification
GA111830Medicare Oscar/Certification
GA111919Medicare Oscar/Certification