Provider Demographics
NPI:1740215029
Name:OBUDULU, ROSEMARY O (MD)
Entity Type:Individual
Prefix:
First Name:ROSEMARY
Middle Name:O
Last Name:OBUDULU
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 1:12315 EVENING BAY DR
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-8829
Mailing Address - Country:US
Mailing Address - Phone:832-367-9620
Mailing Address - Fax:
Practice Address - Street 1:12315 EVENING BAY DR
Practice Address - Street 2:
Practice Address - City:PEARLAND
Practice Address - State:TX
Practice Address - Zip Code:77584-8829
Practice Address - Country:US
Practice Address - Phone:832-367-9620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057205A208M00000X
TXM5416208D00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64059827Medicaid
IN000000279227OtherBCBS - MARY STREET
IN000000386247OtherBCBS - GATEWAY
IN110246808OtherRR MCARE PIN
IN200415150Medicaid
IN639620UUMedicare ID - Type Unspecified
IN200415150Medicaid