1649445644 NPI number — IVIE OYENMWEN OMORUYI IDEHEN C.N.M

Table of content: IVIE OYENMWEN OMORUYI IDEHEN C.N.M (NPI 1649445644)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649445644 NPI number — IVIE OYENMWEN OMORUYI IDEHEN C.N.M

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OMORUYI IDEHEN
Provider First Name:
IVIE
Provider Middle Name:
OYENMWEN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C.N.M
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OMORUYI
Provider Other First Name:
IVIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1649445644
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/21/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
151 DANIEL LOW TER
Provider Second Line Business Mailing Address:
1C
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10301-2358
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-913-0990
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 BROOKDALE PLZ
Provider Second Line Business Practice Location Address:
ROOM 221 KATZ
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11212-3139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-240-6278
Provider Business Practice Location Address Fax Number:
718-240-8062
Provider Enumeration Date:
04/30/2008

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: 176B00000X , with the licence number:  25ME00043401 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 176B00000X , with the licence number: 001252 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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