Healthcare Provider Details

I. General information

NPI: 1659639730
Provider Name (Legal Business Name): OBOSA MEDICAL SERVICES,PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2012
Last Update Date: 04/26/2012
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

11 GOLDEN RD
MONTEBELLO NY
10901-3220
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 Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number193487
License Number StateNY

VIII. Authorized Official

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