Provider Demographics
NPI:1700427390
Name:OTA, NKEMDIRIM
Entity Type:Individual
Prefix:MR
First Name:NKEMDIRIM
Middle Name:
Last Name:OTA
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 1:2325 DELMAR AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-6819
Mailing Address - Country:US
Mailing Address - Phone:267-237-6561
Mailing Address - Fax:
Practice Address - Street 1:2325 DELMAR AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6819
Practice Address - Country:US
Practice Address - Phone:267-237-6561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-04
Last Update Date:2019-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR13397600163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2156710323Medicaid