Provider Demographics
NPI:1992367478
Name:OKON-UMOREN, ANIEBIETABASI (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIEBIETABASI
Middle Name:
Last Name:OKON-UMOREN
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:ONE FORD PLACE 2E
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202
Mailing Address - Country:US
Mailing Address - Phone:313-874-5378
Mailing Address - Fax:313-916-2018
Practice Address - Street 1:2799 W GRAND BOULEVARD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202
Practice Address - Country:US
Practice Address - Phone:313-916-1601
Practice Address - Fax:313-916-2018
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2020-03-09
Deactivation Date:2020-02-17
Deactivation Code:
Reactivation Date:2020-03-09
Provider Licenses
StateLicense IDTaxonomies
MI4351044811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine