Healthcare Provider Details

I. General information

NPI: 1619323367
Provider Name (Legal Business Name): OSAMA AHMAD ODEH AL DALAHMAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2016
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date: 01/05/2017
Reactivation Date: 04/29/2020

III. Provider practice location address

630 WEST , 168TH STREET DEPARTMENT OF PATHOLOGY AND CELL BIOLOGY, ROOM PH15-124
NEW YORK NY
10032
US

IV. Provider business mailing address

630 WEST , 168TH STREET DEPARTMENT OF PATHOLOGY AND CELL BIOLOGY, ROOM PH15-124
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-7012
  • Fax:
Mailing address:
  • Phone: 212-305-7012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberMD047974
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberMD047974
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License Number305676
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: