Provider Demographics
NPI:1558914341
Name:OOMMEN, SONU WILSON
Entity Type:Individual
Prefix:DR
First Name:SONU
Middle Name:WILSON
Last Name:OOMMEN
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 1:8047 254TH ST
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1219
Mailing Address - Country:US
Mailing Address - Phone:347-551-6886
Mailing Address - Fax:
Practice Address - Street 1:10745 GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11433-2351
Practice Address - Country:US
Practice Address - Phone:347-551-6886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-20
Last Update Date:2019-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY063485183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist