Provider Demographics
NPI:1770519928
Name:NWASOKWA, OBI N (MD)
Entity type:Individual
Prefix:
First Name:OBI
Middle Name:N
Last Name:NWASOKWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 LINDEN BLVD
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-1142
Mailing Address - Country:US
Mailing Address - Phone:718-479-7808
Mailing Address - Fax:718-479-7491
Practice Address - Street 1:22001 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-2140
Practice Address - Country:US
Practice Address - Phone:718-479-7808
Practice Address - Fax:718-479-7491
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2016-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169721207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0061136OtherGHI
NY01045743Medicaid
NY01045743Medicaid
NY61136Medicare ID - Type Unspecified
NYB88722Medicare UPIN