Provider Demographics
NPI:1780176925
Name:OBASEKI, BENJAMIN OLU ALAN (MD)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:OLU ALAN
Last Name:OBASEKI
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 1:3311 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46205-3825
Mailing Address - Country:US
Mailing Address - Phone:929-375-1242
Mailing Address - Fax:
Practice Address - Street 1:2401 W UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303-3428
Practice Address - Country:US
Practice Address - Phone:765-747-3241
Practice Address - Fax:765-281-6567
Is Sole Proprietor?:No
Enumeration Date:2018-06-04
Last Update Date:2024-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01085698A207QA0401X
IN01085608A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00263392OtherRAILROAD PTAN
IN264430C74OtherMEDICARE PTAN
IN300049390Medicaid
IN000001542700OtherANTHEM PTAN