Provider Demographics
NPI:1275853129
Name:SHOBIN OOMMEN PHYSICIAN, PC
Entity Type:Organization
Organization Name:SHOBIN OOMMEN PHYSICIAN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SHOBIN
Authorized Official - Middle Name:
Authorized Official - Last Name:OOMMEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-797-4421
Mailing Address - Street 1:877 STEWART AVE
Mailing Address - Street 2:SUITE 16
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-4803
Mailing Address - Country:US
Mailing Address - Phone:516-745-6918
Mailing Address - Fax:
Practice Address - Street 1:35 PILGRIM ST
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-3140
Practice Address - Country:US
Practice Address - Phone:917-797-4421
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2010-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246228103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty