Healthcare Provider Details

I. General information

NPI: 1083001408
Provider Name (Legal Business Name): MUMUNI T. DAODU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/23/2015
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 LAKE AVE N DEPARTMENT OF CRITICAL CARE
WORCESTER MA
01655-0002
US

IV. Provider business mailing address

200 MILL RD STE 180
FAIRHAVEN MA
02719-5255
US

V. Phone/Fax

Practice location:
  • Phone: 774-442-6534
  • Fax: 774-443-0037
Mailing address:
  • Phone: 508-973-2000
  • Fax: 508-973-2001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number2299476
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN2299476
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: