Provider Demographics
NPI:1467748657
Name:UMOBONG, ETIENO USEN (MD)
Entity Type:Individual
Prefix:
First Name:ETIENO
Middle Name:USEN
Last Name:UMOBONG
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 1:2005 TECHNOLOGY PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-9423
Mailing Address - Country:US
Mailing Address - Phone:717-988-5864
Mailing Address - Fax:717-221-5615
Practice Address - Street 1:2005 TECHNOLOGY PKWY STE 300
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-9423
Practice Address - Country:US
Practice Address - Phone:717-988-5864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-26
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD471227207R00000X, 207RP1001X
PAMT200560208600000X
NYTO BE ISSUED390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103787651Medicaid