Provider Demographics
NPI:1245490259
Name:OMOGBAI, TIMOTHY OMOKHOGIE (REGISTERED NURSE)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:OMOKHOGIE
Last Name:OMOGBAI
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 STRATFORD RD
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:NY
Mailing Address - Zip Code:12775-6129
Mailing Address - Country:US
Mailing Address - Phone:845-794-2024
Mailing Address - Fax:
Practice Address - Street 1:20 STRATFORD RD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:NY
Practice Address - Zip Code:12775-6129
Practice Address - Country:US
Practice Address - Phone:845-794-2024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY508490163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse