Healthcare Provider Details

I. General information

NPI: 1376855734
Provider Name (Legal Business Name): KOME S OSEGHALE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2010
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 MAIN STREET SUITE 200
OGDENSBURG NY
13669
US

IV. Provider business mailing address

305 MAIN STREET SUITE 200
OGDENSBURG NY
13669
US

V. Phone/Fax

Practice location:
  • Phone: 315-713-6770
  • Fax: 877-902-6131
Mailing address:
  • Phone: 315-713-6770
  • Fax: 877-902-6131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number272702
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: