Provider Demographics
NPI:1780004358
Name:OMER TIPU PHYSICIAN PC
Entity Type:Organization
Organization Name:OMER TIPU PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:OMER
Authorized Official - Middle Name:
Authorized Official - Last Name:TIPU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-972-4200
Mailing Address - Street 1:710 SUNNYVIEW OVAL
Mailing Address - Street 2:
Mailing Address - City:KEASBEY
Mailing Address - State:NJ
Mailing Address - Zip Code:08832-1039
Mailing Address - Country:US
Mailing Address - Phone:718-972-4200
Mailing Address - Fax:
Practice Address - Street 1:446 MCDONALD AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-2212
Practice Address - Country:US
Practice Address - Phone:718-972-4200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-23
Last Update Date:2014-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03850084Medicaid
NY03850084Medicaid