Provider Demographics
NPI:1942881404
Name:OMADEVUAE, DIETANURUN BOSE
Entity Type:Individual
Prefix:
First Name:DIETANURUN
Middle Name:BOSE
Last Name:OMADEVUAE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIETANURUN
Other - Middle Name:BOSE
Other - Last Name:OMADEVUAE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:300 INTERNATIONAL PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-5028
Mailing Address - Country:US
Mailing Address - Phone:866-610-0580
Mailing Address - Fax:
Practice Address - Street 1:10920 MOSS PARK RD
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32832-6086
Practice Address - Country:US
Practice Address - Phone:407-930-4339
Practice Address - Fax:407-745-1326
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician