1558067538 NPI number — DR-DO-OMM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1558067538 NPI number — DR-DO-OMM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR-DO-OMM
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1558067538
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/17/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 NEW SOUTH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AMHERST
Provider Business Mailing Address State Name:
NH
Provider Business Mailing Address Postal Code:
03031-1606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
603-759-1575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
292 ROUTE 101 UNIT F-1
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AMHERST
Provider Business Practice Location Address State Name:
NH
Provider Business Practice Location Address Postal Code:
03031-1730
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
603-341-9144
Provider Business Practice Location Address Fax Number:
949-864-3717
Provider Enumeration Date:
02/01/2023

Additional Information

Authorized Official

Authorized Official Last Name:
SULLIVAN
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
C
Authorized Official Title or Position:
PHYSICIAN/ OWNER
Authorized Official Telephone Number:
603-341-9144

Provider Taxonomy Codes

  • Taxonomy code: 204D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1023422748 , issued by the state of ( NH ) . This identifiers is of the category "MEDICAID".




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