MEDICARE: MRS. SUSIE HICKS ODUMGBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1740608066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSIE HICKS ODUMGBA

Provider Business Mailing Address
First Line	:	374 RUTLAND RD APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11225-6116
Country	:	US
Telephone Number	:	718-756-3959
Fax Number	:

Provider Business Practice Location Address
First Line	:	374 RUTLAND RD APT 2F
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11225-6116
Country	:	US
Telephone Number	:	718-756-3959
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2014
Last Update Date	:	08/11/2016

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