Provider Demographics
NPI:1407385131
Name:AMADASUN, OWEN (MD/MBA)
Entity Type:Individual
Prefix:DR
First Name:OWEN
Middle Name:
Last Name:AMADASUN
Suffix:
Gender:M
Credentials:MD/MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 CORNELL CIR
Mailing Address - Street 2:
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-1422
Mailing Address - Country:US
Mailing Address - Phone:860-655-5494
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-06
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY306109208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program