Basic Information
| Provider Information | |||||||||
| NPI: | 1275633786 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UDEAGBALA | ||||||||
| FirstName: | BENEDICTA | ||||||||
| MiddleName: | OLAMIDE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1395 NW 167TH ST | ||||||||
| Address2: | |||||||||
| City: | MIAMI GARDENS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331695710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413577950 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1505 53RD AVE E | ||||||||
| Address2: | |||||||||
| City: | BRADENTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 342034249 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9413577950 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2006 | ||||||||
| LastUpdateDate: | 05/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34006079 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OS17771 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0241812 | 05 | OH | MEDICAID |