Provider Demographics
NPI:1023075058
Name:OBENG, JOSEPH YAW (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:YAW
Last Name:OBENG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 MALL CIR
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-1546
Mailing Address - Country:US
Mailing Address - Phone:817-870-1033
Mailing Address - Fax:817-900-0309
Practice Address - Street 1:2600 MALL CIR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116-1546
Practice Address - Country:US
Practice Address - Phone:817-870-1033
Practice Address - Fax:817-900-0309
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM0200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170083301Medicaid
TX170083301Medicaid
TXTXB148464Medicare PIN
TX8C7863Medicare PIN