Healthcare Provider Details

I. General information

NPI: 1285995324
Provider Name (Legal Business Name): JENICA O'MALLEY DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2012
Last Update Date: 05/22/2023
Certification Date: 05/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 EAST ADAMS ST 4TH FL
SYRACUSE NY
13210-2576
US

IV. Provider business mailing address

725 EAST ADAMS ST 4TH FL
SYRACUSE NY
13210-2576
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5831
  • Fax: 315-464-2030
Mailing address:
  • Phone: 315-464-5831
  • Fax: 315-464-2030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number279084
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier04277845
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: