Healthcare Provider Details

I. General information

NPI: 1164460804
Provider Name (Legal Business Name): CLEMENTINA OKUNPOLOR M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 BROADWAY WOODHULL MEDICAL AND MENTAL HEALTH CENTER
BROOKLYN NY
11206-5317
US

IV. Provider business mailing address

234 HENDRICKSON AVE
LYNBROOK NY
11563-1023
US

V. Phone/Fax

Practice location:
  • Phone: 718-963-8000
  • Fax:
Mailing address:
  • Phone: 646-436-5352
  • Fax: 516-812-8597

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number226833
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: