Provider Demographics
NPI:1942642038
Name:EBENEZER ODOOM MD PC
Entity Type:Organization
Organization Name:EBENEZER ODOOM MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:EBENEZER
Authorized Official - Middle Name:
Authorized Official - Last Name:ODOOM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-276-4570
Mailing Address - Street 1:21530 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11427-1831
Mailing Address - Country:US
Mailing Address - Phone:718-740-1701
Mailing Address - Fax:718-740-1901
Practice Address - Street 1:21530 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1831
Practice Address - Country:US
Practice Address - Phone:718-740-1701
Practice Address - Fax:718-740-1901
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty