Provider Demographics
NPI:1770579492
Name:OBIESIE, NDIDIAMAKA UZOMA (MD)
Entity type:Individual
Prefix:
First Name:NDIDIAMAKA
Middle Name:UZOMA
Last Name:OBIESIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NDIDIAMAKA
Other - Middle Name:
Other - Last Name:OKAFOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:530 E MCDOWELL RD STE 107-609
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85004-1549
Mailing Address - Country:US
Mailing Address - Phone:602-790-4108
Mailing Address - Fax:623-516-9319
Practice Address - Street 1:3330 N 2ND ST STE 401
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85012-2371
Practice Address - Country:US
Practice Address - Phone:602-254-1136
Practice Address - Fax:602-279-1720
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-27
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30584207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ763062Medicaid
AZ71505Medicare ID - Type Unspecified
AZ763062Medicaid
H74791Medicare UPIN