1780004358 NPI number — OMER TIPU PHYSICIAN PC

Table of content: (NPI 1780004358)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780004358 NPI number — OMER TIPU PHYSICIAN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OMER TIPU PHYSICIAN PC
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:
1780004358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/01/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
710 SUNNYVIEW OVAL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KEASBEY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08832-1039
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-972-4200
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
446 MCDONALD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11218-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-972-4200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2014

Additional Information

Authorized Official

Authorized Official Last Name:
TIPU
Authorized Official First Name:
OMER
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-972-4200

Provider Taxonomy Codes

  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03850084 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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