1831495266 NPI number — DR. KENECHI ANIKWE OBETTA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831495266 NPI number — DR. KENECHI ANIKWE OBETTA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OBETTA
Provider First Name:
KENECHI
Provider Middle Name:
ANIKWE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OBETTA
Provider Other First Name:
THANKGOD
Provider Other Middle Name:
ANIKWE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1831495266
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 PRESTIGE PL STE 550
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIAMISBURG
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45342-6115
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-762-1305
Provider Business Mailing Address Fax Number:
937-522-7513

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4750 30 E APPLE ST
Provider Second Line Business Practice Location Address:
SUITE 6250
Provider Business Practice Location Address City Name:
DAYTON
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45409-2939
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-208-8394
Provider Business Practice Location Address Fax Number:
937-208-8388
Provider Enumeration Date:
02/02/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  PENDING , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 0101273731 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 35.096931 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 35096931 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0052178 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".