Provider Demographics
NPI:1982757878
Name:OBI, VIVIAN C
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:C
Last Name:OBI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 BLEECKER ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2413
Mailing Address - Country:US
Mailing Address - Phone:212-274-7250
Mailing Address - Fax:
Practice Address - Street 1:26 BLEECKER ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10012-2413
Practice Address - Country:US
Practice Address - Phone:212-274-7250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335051363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02828251Medicaid