Provider Demographics
NPI:1639323348
Name:EHIMIAGHE, OMON
Entity Type:Individual
Prefix:
First Name:OMON
Middle Name:
Last Name:EHIMIAGHE
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 1:50 NEVINS ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-1004
Mailing Address - Country:US
Mailing Address - Phone:718-834-9112
Mailing Address - Fax:
Practice Address - Street 1:50 NEVINS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11217-1004
Practice Address - Country:US
Practice Address - Phone:718-834-9112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator