Provider Demographics
NPI:1952786659
Name:DWOMOH, IVY (MD)
Entity Type:Individual
Prefix:DR
First Name:IVY
Middle Name:
Last Name:DWOMOH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 E 167TH ST APT 6B
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10456-4054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:506 LENOX AVNEUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT60106208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program