Provider Demographics
NPI:1639331317
Name:EDO-OHONBA, OSAZE (MD)
Entity Type:Individual
Prefix:
First Name:OSAZE
Middle Name:
Last Name:EDO-OHONBA
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 1:1600 E BROADWAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-5844
Mailing Address - Country:US
Mailing Address - Phone:573-815-8000
Mailing Address - Fax:
Practice Address - Street 1:1600 EAST BROADWAY
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5844
Practice Address - Country:US
Practice Address - Phone:573-815-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-25
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT 185563207R00000X
MO2018019491207R00000X, 207RP1001X, 207RC0200X
IN01065638A208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200908800Medicaid
IN260690EEMedicare PIN
IN200908800Medicaid
IN058490WWWWMedicare PIN