1114966157 NPI number — DR. OWOBAMISHOLA SHONOWO MD

Table of content: DR. OWOBAMISHOLA SHONOWO MD (NPI 1114966157)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114966157 NPI number — DR. OWOBAMISHOLA SHONOWO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHONOWO
Provider First Name:
OWOBAMISHOLA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114966157
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
565 NEW BRUNSWICK AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORDS
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08863
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
848-203-3520
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
565 NEW BRUNSWICK AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORDS
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08863-2162
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
848-203-3520
Provider Business Practice Location Address Fax Number:
848-203-3627
Provider Enumeration Date:
06/05/2006

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: 207V00000X , with the licence number:  25MA07930600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 274327299 . This is a "TAX ID#" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 7546474 . This is a "AETNA PPO ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: P3653473 . This is a "OXFORD ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 1118997 . This is a "AETNA HMO ID #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 2678996000 . This is a "AMERIHEALTH #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".
  • Identifier: 8223752 . This is a "GHI PPO #" identifier , issued by the state of ( NJ ) . This identifiers is of the category "OTHER".




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