Provider Demographics
NPI:1053521583
Name:OBUA, OKECHUKWU ERNEST (MD)
Entity type:Individual
Prefix:DR
First Name:OKECHUKWU
Middle Name:ERNEST
Last Name:OBUA
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 1:13902 LITTLE CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77077-1958
Mailing Address - Country:US
Mailing Address - Phone:214-621-4604
Mailing Address - Fax:
Practice Address - Street 1:590 NAAMANS RD
Practice Address - Street 2:
Practice Address - City:CLAYMONT
Practice Address - State:DE
Practice Address - Zip Code:19703-2308
Practice Address - Country:US
Practice Address - Phone:833-886-2277
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP0920207QA0401X
DEC1-0011566207QA0401X, 207Q00000X
PAMD438370261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEC1-0011566Medicaid