Provider Demographics
NPI:1952543852
Name:MBA, OBIANUJU (MD)
Entity Type:Individual
Prefix:
First Name:OBIANUJU
Middle Name:
Last Name:MBA
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 1:2030 MOUNTAIN VIEW AVE
Mailing Address - Street 2:250
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80501-3178
Mailing Address - Country:US
Mailing Address - Phone:303-485-4243
Mailing Address - Fax:303-485-4240
Practice Address - Street 1:2030 MOUNTAIN VIEW AVE
Practice Address - Street 2:250
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-3178
Practice Address - Country:US
Practice Address - Phone:303-485-4243
Practice Address - Fax:303-485-4240
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-24
Last Update Date:2012-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT194305207Q00000X
CO51560208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine