Provider Demographics
NPI:1508641002
Name:OBOH, THOMAS
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:OBOH
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 1:16 14TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-3032
Mailing Address - Country:US
Mailing Address - Phone:862-235-7556
Mailing Address - Fax:
Practice Address - Street 1:44 GLENWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07017
Practice Address - Country:US
Practice Address - Phone:862-235-7256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-31
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJHP0352900251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ920356930OtherMEDICARE
NJ920356930Medicaid