Provider Demographics
NPI:1689840472
Name:UBOM, BRENDA (DO)
Entity Type:Individual
Prefix:DR
First Name:BRENDA
Middle Name:
Last Name:UBOM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24410 SANTA BARBARA ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-6813
Mailing Address - Country:US
Mailing Address - Phone:248-559-9286
Mailing Address - Fax:
Practice Address - Street 1:3001 MILLER RD
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1458
Practice Address - Country:US
Practice Address - Phone:313-323-0045
Practice Address - Fax:313-845-4626
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101007548208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice