Provider Demographics
NPI:1093944860
Name:OTUGH, MICHAEL IFEANYI (NP)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:IFEANYI
Last Name:OTUGH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 HEMPSTEAD AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:WEST HEMPSTEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11552-2050
Mailing Address - Country:US
Mailing Address - Phone:516-500-9905
Mailing Address - Fax:516-500-9533
Practice Address - Street 1:354 HEMPSTEAD AVE STE 101
Practice Address - Street 2:
Practice Address - City:WEST HEMPSTEAD
Practice Address - State:NY
Practice Address - Zip Code:11552-2050
Practice Address - Country:US
Practice Address - Phone:516-500-9905
Practice Address - Fax:516-500-9533
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY307338363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health