Healthcare Provider Details

I. General information

NPI: 1982718060
Provider Name (Legal Business Name): GODFREY U MBONU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914A COLUMBUS AVE
NEW YORK NY
10025-4040
US

IV. Provider business mailing address

914A COLUMBUS AVE
NEW YORK NY
10025-4040
US

V. Phone/Fax

Practice location:
  • Phone: 212-749-2482
  • Fax: 212-749-2484
Mailing address:
  • Phone: 212-749-2482
  • Fax: 212-749-2484

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number226508-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: