Provider Demographics
NPI:1629212444
Name:OMAGHOMI, JOSEPH RICHARD
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:RICHARD
Last Name:OMAGHOMI
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 1:1988 N D ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-3912
Mailing Address - Country:US
Mailing Address - Phone:909-886-5209
Mailing Address - Fax:909-886-5235
Practice Address - Street 1:1988 N D ST
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-3912
Practice Address - Country:US
Practice Address - Phone:909-886-5209
Practice Address - Fax:909-886-5235
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-23
Last Update Date:2009-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50768332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies