Provider Demographics
NPI:1710904560
Name:OSOBA, OLUMIDE (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUMIDE
Middle Name:
Last Name:OSOBA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:175 WILLOUGHBY ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-5463
Mailing Address - Country:US
Mailing Address - Phone:718-246-6451
Mailing Address - Fax:718-246-6465
Practice Address - Street 1:175 WILLOUGHBY ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-5463
Practice Address - Country:US
Practice Address - Phone:718-246-6451
Practice Address - Fax:718-246-6465
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155213207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00815403Medicaid
NY00815403Medicaid
NY11D611Medicare ID - Type Unspecified