Provider Demographics
NPI:1790026060
Name:EMMANUEL N. MBA, M.D., INC.
Entity Type:Organization
Organization Name:EMMANUEL N. MBA, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EMMANUEL
Authorized Official - Middle Name:N
Authorized Official - Last Name:MBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-677-7172
Mailing Address - Street 1:5640 W 62ND ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90056-2009
Mailing Address - Country:US
Mailing Address - Phone:310-677-7172
Mailing Address - Fax:310-677-2658
Practice Address - Street 1:325 E HILLCREST BLVD
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-2405
Practice Address - Country:US
Practice Address - Phone:310-677-7172
Practice Address - Fax:310-677-2658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-11
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG19040174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40488Medicare UPIN