1548588775 NPI number — DR. CLINT JOSEPH OOMMEN M.D.

Table of content: DR. CLINT JOSEPH OOMMEN M.D. (NPI 1548588775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548588775 NPI number — DR. CLINT JOSEPH OOMMEN M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OOMMEN
Provider First Name:
CLINT
Provider Middle Name:
JOSEPH
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

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:
1548588775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 MILFORD STREET, SUITE 605
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SALISBURY
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21804
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-334-2227
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 MATTHEW ST STE 302
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45750-1656
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
740-568-5207
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/12/2010

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: 207RC0000X , with the licence number:  35.137006 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207R00000X , with the licence number: 49431 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

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




Copyright © 2007-2025 www.npivalidator.com