Provider Demographics
NPI:1285039636
Name:TAIWO, CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:
Last Name:TAIWO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8350
Mailing Address - Country:US
Mailing Address - Phone:631-444-2478
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK MEDICINE
Practice Address - Street 2:DEPT. OF EMERGENCY MEDICINE, HSC, LEVEL 4, ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8350
Practice Address - Country:US
Practice Address - Phone:631-444-2478
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-28
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant