Provider Demographics
NPI:1013472323
Name:IFIDON, LAWRENCE OSE II
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:OSE
Last Name:IFIDON
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 ROSSITER AVE
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-5008
Mailing Address - Country:US
Mailing Address - Phone:646-242-8956
Mailing Address - Fax:
Practice Address - Street 1:529 COURTLANDT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5007
Practice Address - Country:US
Practice Address - Phone:718-654-0730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker