Provider Demographics
NPI:1295791275
Name:WALUSIMBI, MBAGA S (MD)
Entity type:Individual
Prefix:
First Name:MBAGA
Middle Name:S
Last Name:WALUSIMBI
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 1:725 UNIVERSITY BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45435-0001
Mailing Address - Country:US
Mailing Address - Phone:937-245-7100
Mailing Address - Fax:937-245-7999
Practice Address - Street 1:30 EAST APPLE STREET
Practice Address - Street 2:SUITE 5253
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409
Practice Address - Country:US
Practice Address - Phone:937-208-2552
Practice Address - Fax:937-208-6154
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2018-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0844912086S0127X
OH35084491208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2483594Medicaid
F94030Medicare UPIN
WA4134381Medicare PIN