Healthcare Provider Details

I. General information

NPI: 1104487453
Provider Name (Legal Business Name): SALOME WIREDU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2019
Last Update Date: 06/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BROOKDALE PLZ
BROOKLYN NY
11212-3198
US

IV. Provider business mailing address

1315 E 104TH ST
BROOKLYN NY
11236-4507
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-5000
  • Fax:
Mailing address:
  • Phone: 647-771-6159
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number10128825
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: