MEDICARE: GODFREY U MBONU M.D

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	2084P0804X	Child & Adolescent Psychiatry Physician	226508-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1982718060
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GODFREY U MBONU M.D

Provider Business Mailing Address
First Line	:	914A COLUMBUS AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-4040
Country	:	US
Telephone Number	:	212-749-2482
Fax Number	:	212-749-2484

Provider Business Practice Location Address
First Line	:	914A COLUMBUS AVE
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10025-4040
Country	:	US
Telephone Number	:	212-749-2482
Fax Number	:	212-749-2484

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

Provider Enumeration Date	:	08/18/2006
Last Update Date	:	07/08/2007

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