Healthcare Provider Details

I. General information

NPI: 1467316208
Provider Name (Legal Business Name): MR. CHARLES OSAKIDUWA OMOZUWA SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 BEACH 36TH ST APT 3
FAR ROCKAWAY NY
11691-1507
US

IV. Provider business mailing address

436 BEACH 36TH ST APT 3
FAR ROCKAWAY NY
11691-1507
US

V. Phone/Fax

Practice location:
  • Phone: 347-972-1288
  • Fax:
Mailing address:
  • Phone: 347-972-1288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number337790
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: