Healthcare Provider Details

I. General information

NPI: 1134289499
Provider Name (Legal Business Name): OSAFRADU OPAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2006
Last Update Date: 07/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8900 VAN WYCK EXPY
JAMAICA NY
11418-2897
US

IV. Provider business mailing address

80 MARCUS DR
MELVILLE NY
11747-4230
US

V. Phone/Fax

Practice location:
  • Phone: 718-206-7001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number192310
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: