Provider Demographics
NPI:1710002613
Name:ISIADINSO, OBINNA A (MD)
Entity Type:Individual
Prefix:
First Name:OBINNA
Middle Name:A
Last Name:ISIADINSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OBINNA
Other - Middle Name:A
Other - Last Name:ISIADINSO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD, PHD
Mailing Address - Street 1:19 WOOD ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-4411
Mailing Address - Country:US
Mailing Address - Phone:845-486-1069
Mailing Address - Fax:
Practice Address - Street 1:19 WOOD ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-4411
Practice Address - Country:US
Practice Address - Phone:845-486-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119153207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY119153Medicaid
NY34D832OtherMEDICARE PROVIDER # 34D832
NY012953301137361Medicaid
NY34D832OtherMEDICARE PROVIDER # 34D832