Healthcare Provider Details

I. General information

NPI: 1588929418
Provider Name (Legal Business Name): MS. CARMEN OBANDO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2012
Last Update Date: 07/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2431 SOUTHERN BLVD APT 1
BRONX NY
10458-6520
US

IV. Provider business mailing address

2431 SOUTHERN BLVD APT 1
BRONX NY
10458-6520
US

V. Phone/Fax

Practice location:
  • Phone: 347-271-3324
  • Fax: 718-299-6578
Mailing address:
  • Phone: 347-271-3324
  • Fax: 718-299-6578

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number640027
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: