Provider Demographics
NPI:1831495266
Name:OBETTA, KENECHI ANIKWE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENECHI
Middle Name:ANIKWE
Last Name:OBETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:THANKGOD
Other - Middle Name:ANIKWE
Other - Last Name:OBETTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1305
Mailing Address - Fax:937-522-7513
Practice Address - Street 1:4750 30 E APPLE ST
Practice Address - Street 2:SUITE 6250
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2939
Practice Address - Country:US
Practice Address - Phone:937-208-8394
Practice Address - Fax:937-208-8388
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPENDING207R00000X
VA0101273731207R00000X
OH35.096931208M00000X
OH35096931207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0052178Medicaid
OHH016460Medicare PIN