Provider Demographics
NPI:1528226677
Name:IDAHOSA, VICTOR OMAMODE (MD)
Entity Type:Individual
Prefix:
First Name:VICTOR
Middle Name:OMAMODE
Last Name:IDAHOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:348 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:NY
Mailing Address - Zip Code:14892-1441
Mailing Address - Country:US
Mailing Address - Phone:607-821-2444
Mailing Address - Fax:607-821-2444
Practice Address - Street 1:348 BROAD ST
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:NY
Practice Address - Zip Code:14892-1441
Practice Address - Country:US
Practice Address - Phone:607-821-2444
Practice Address - Fax:607-948-1030
Is Sole Proprietor?:No
Enumeration Date:2008-05-27
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY276514207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine