Healthcare Provider Details

I. General information

NPI: 1659609873
Provider Name (Legal Business Name): EMMANUEL M OTUADA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2009
Last Update Date: 11/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

790 ELDERT LN 16E
BROOKLYN NY
11208-4753
US

IV. Provider business mailing address

790 ELDERT LN 16E
BROOKLYN NY
11208-4753
US

V. Phone/Fax

Practice location:
  • Phone: 917-548-3711
  • Fax: 718-235-3723
Mailing address:
  • Phone: 917-548-3711
  • Fax: 718-235-3723

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number579457
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: