Provider Demographics
NPI:1295839546
Name:OMOHUNDRO, DAN CHARLES SR (MD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:CHARLES
Last Name:OMOHUNDRO
Suffix:SR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2371 BLACK ROCK TPKE
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825
Mailing Address - Country:US
Mailing Address - Phone:203-371-0141
Mailing Address - Fax:203-371-6585
Practice Address - Street 1:2371 BLACK ROCK TPKE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825
Practice Address - Country:US
Practice Address - Phone:203-371-0141
Practice Address - Fax:203-371-6585
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT020114207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1201144Medicaid
180000223Medicare ID - Type Unspecified
B39061Medicare UPIN