Provider Demographics
NPI:1497445068
Name:OMOYEFA, ABIDEMI
Entity Type:Individual
Prefix:
First Name:ABIDEMI
Middle Name:
Last Name:OMOYEFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1324 FOREST AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10302-2044
Mailing Address - Country:US
Mailing Address - Phone:347-791-9818
Mailing Address - Fax:
Practice Address - Street 1:1324 FOREST AVE STE 104
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10302-2044
Practice Address - Country:US
Practice Address - Phone:347-791-9818
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-08
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY510765335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier