Healthcare Provider Details

I. General information

NPI: 1356415970
Provider Name (Legal Business Name): TAIYE O ODEDOSU M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

462 1ST AVENUE, 27TH STREET, BELLEVUE HOSPITAL MODULE C,
NEW YORK NY
10016
US

IV. Provider business mailing address

225 E 95TH ST APT 20K
NEW YORK NY
10128-4007
US

V. Phone/Fax

Practice location:
  • Phone: 212-562-1619
  • Fax:
Mailing address:
  • Phone: 917-952-9562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number238193
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: