Provider Demographics
NPI:1508193988
Name:MBAH, STEPHEN OBIORAH
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:OBIORAH
Last Name:MBAH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 KINGSWOOD CT
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-7545
Mailing Address - Country:US
Mailing Address - Phone:817-521-5144
Mailing Address - Fax:682-518-5706
Practice Address - Street 1:15001 TRINITY BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76155-2647
Practice Address - Country:US
Practice Address - Phone:817-685-0861
Practice Address - Fax:800-456-8966
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-05
Last Update Date:2009-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX40307183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX183500000XMedicaid