Healthcare Provider Details

I. General information

NPI: 1407817398
Provider Name (Legal Business Name): ONYEMACHI GEORGE AJAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2006
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111-02 FARMERS BLVD
SAINT ALBANS NY
11412-2328
US

IV. Provider business mailing address

164 LENOX RD
NORTH BALDWIN NY
11510-1016
US

V. Phone/Fax

Practice location:
  • Phone: 718-454-1466
  • Fax: 718-454-1467
Mailing address:
  • Phone: 718-454-1466
  • Fax: 718-554-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number229630
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: