Healthcare Provider Details

I. General information

NPI: 1538103825
Provider Name (Legal Business Name): IWUOZO L OBILO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 03/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 CHESTNUT ST
SPRING VALLEY NY
10977-5533
US

IV. Provider business mailing address

21 CHESTNUT ST
SPRING VALLEY NY
10977-5533
US

V. Phone/Fax

Practice location:
  • Phone: 845-371-0034
  • Fax: 845-371-7014
Mailing address:
  • Phone: 845-371-0034
  • Fax: 845-371-7014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA07018500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier8279705
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: