Healthcare Provider Details

I. General information

NPI: 1942642038
Provider Name (Legal Business Name): EBENEZER ODOOM MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21530 HILLSIDE AVE
QUEENS VILLAGE NY
11427-1831
US

IV. Provider business mailing address

21530 HILLSIDE AVE
QUEENS VILLAGE NY
11427-1831
US

V. Phone/Fax

Practice location:
  • Phone: 718-740-1701
  • Fax: 718-740-1901
Mailing address:
  • Phone: 718-740-1701
  • Fax: 718-740-1901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: EBENEZER ODOOM
Title or Position: PRESIDENT
Credential: MD
Phone: 347-276-4570