Healthcare Provider Details

I. General information

NPI: 1194055012
Provider Name (Legal Business Name): OBOSA MEDICAL CARE, P.L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 12/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 STEVENS AVE
MOUNT VERNON NY
10550-2515
US

IV. Provider business mailing address

140 STEVENS AVE
MOUNT VERNON NY
10550-2515
US

V. Phone/Fax

Practice location:
  • Phone: 914-530-2323
  • Fax: 914-530-2320
Mailing address:
  • Phone: 914-530-2323
  • Fax: 914-530-2320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: FRANCIS AGBONKPOLO
Title or Position: CEO
Credential: M.D.
Phone: 914-530-2323