Provider Demographics
NPI:1770796336
Name:QUIAMBAO, BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:QUIAMBAO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:BENJAMIN
Other - Middle Name:Y
Other - Last Name:QUIAMBAO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 6708
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73153-0708
Mailing Address - Country:US
Mailing Address - Phone:405-790-0500
Mailing Address - Fax:405-790-0501
Practice Address - Street 1:3750 W MAIN ST STE AA
Practice Address - Street 2:
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73072-4645
Practice Address - Country:US
Practice Address - Phone:405-790-0500
Practice Address - Fax:405-790-0501
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-08
Last Update Date:2024-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK247082084P0804X, 2084P0800X
CAC1495572084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200271930AMedicaid
OK200238960AMedicaid