Provider Demographics
NPI:1740608066
Name:ODUMGBA, SUSIE HICKS
Entity Type:Individual
Prefix:MRS
First Name:SUSIE
Middle Name:HICKS
Last Name:ODUMGBA
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 1:374 RUTLAND RD APT 2F
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-6116
Mailing Address - Country:US
Mailing Address - Phone:718-756-3959
Mailing Address - Fax:
Practice Address - Street 1:374 RUTLAND RD APT 2F
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11225-6116
Practice Address - Country:US
Practice Address - Phone:718-756-3959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist