Provider Demographics
NPI:1487648283
Name:ODUJEBE, HENRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:HENRY
Middle Name:A
Last Name:ODUJEBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 W GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:TINTON FALLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07701-4918
Mailing Address - Country:US
Mailing Address - Phone:732-212-0060
Mailing Address - Fax:
Practice Address - Street 1:495 N 13TH ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07107-1317
Practice Address - Country:US
Practice Address - Phone:973-268-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-07
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05474800207P00000X, 208600000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7025106Medicaid
NJP00357155OtherRAILROAD MEDICARE
NJ449884 P7DMedicare PIN
NJ7025106Medicaid
NJ449884MK5Medicare PIN
NM449884CLDMedicare PIN
NJ449884UXLMedicare PIN
NJF69934Medicare UPIN
NJ449884Medicare ID - Type Unspecified
NJ449884P7EMedicare PIN
NJ449884DQMMedicare PIN
NJ449884MK3Medicare PIN
NJ449884BE0Medicare PIN
NJ449884 P7FMedicare PIN
NJP00357155OtherRAILROAD MEDICARE
NJ449884NSEMedicare PIN
NJ449884UWXMedicare PIN
NJ449884AA7Medicare PIN