Provider Demographics
NPI:1730145194
Name:UKPONMWAN, OSAHON (MD)
Entity Type:Individual
Prefix:
First Name:OSAHON
Middle Name:
Last Name:UKPONMWAN
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 1:1730 CENTRAL PARK AVE
Mailing Address - Street 2:SUITE 3P
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10710-4905
Mailing Address - Country:US
Mailing Address - Phone:914-779-0141
Mailing Address - Fax:914-779-0144
Practice Address - Street 1:1730 CENTRAL PARK AVE
Practice Address - Street 2:SUITE 3P
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10710-4905
Practice Address - Country:US
Practice Address - Phone:914-779-0141
Practice Address - Fax:914-779-0144
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173320207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01256220Medicaid
NY11F741Medicare ID - Type Unspecified
NY01256220Medicaid