Provider Demographics
NPI:1255513610
Name:OSUNDE, NDIDI MARTINS
Entity type:Individual
Prefix:
First Name:NDIDI
Middle Name:MARTINS
Last Name:OSUNDE
Suffix:
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 1:727 TILDEN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-6191
Mailing Address - Country:US
Mailing Address - Phone:917-340-4008
Mailing Address - Fax:
Practice Address - Street 1:727 TILDEN ST FL 2
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-6191
Practice Address - Country:US
Practice Address - Phone:917-340-4008
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121630367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02681056Medicaid