Healthcare Provider Details

I. General information

NPI: 1780004358
Provider Name (Legal Business Name): OMER TIPU PHYSICIAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2014
Last Update Date: 08/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 MCDONALD AVE
BROOKLYN NY
11218-2212
US

IV. Provider business mailing address

710 SUNNYVIEW OVAL
KEASBEY NJ
08832-1039
US

V. Phone/Fax

Practice location:
  • Phone: 718-972-4200
  • Fax:
Mailing address:
  • Phone: 718-972-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: OMER TIPU
Title or Position: PRESIDENT
Credential: MD
Phone: 718-972-4200