Healthcare Provider Details

I. General information

NPI: 1750006417
Provider Name (Legal Business Name): MR. ADENIYI SUNDAY OKOMODA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2022
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

668 STILL HILL RD
HAMDEN CT
06518-1120
US

IV. Provider business mailing address

668 STILL HILL RD
HAMDEN CT
06518-1120
US

V. Phone/Fax

Practice location:
  • Phone: 860-518-1659
  • Fax:
Mailing address:
  • Phone: 860-518-1659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number181780
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: