Healthcare Provider Details

I. General information

NPI: 1982242525
Provider Name (Legal Business Name): WOUND PROS NEW YORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WHITE SPRUCE BLVD STE 134
BRIGHTON NY
14623
US

IV. Provider business mailing address

4640 ADMIRALTY WAY STE 500
MARINA DEL REY CA
90292-6636
US

V. Phone/Fax

Practice location:
  • Phone: 323-545-3676
  • Fax: 323-433-9177
Mailing address:
  • Phone: 818-836-2475
  • Fax: 323-433-9177

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTOPHER AYODELE OTIKO
Title or Position: PRESIDENT
Credential: MD
Phone: 818-836-2475