Provider Demographics
NPI:1437269925
Name:OGENA, ANNALISSA TABO (MD)
Entity Type:Individual
Prefix:
First Name:ANNALISSA
Middle Name:TABO
Last Name:OGENA
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 1:4315 DIPLOMACY DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-5926
Mailing Address - Country:US
Mailing Address - Phone:907-563-2662
Mailing Address - Fax:
Practice Address - Street 1:4315 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5926
Practice Address - Country:US
Practice Address - Phone:907-563-2662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK5366208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD15911Medicaid
AK8EC098Medicare ID - Type Unspecified
AKH99917Medicare UPIN