=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134195753
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EJIKE ONUOGU MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2006
-----------------------------------------------------
Last Update Date | 05/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 366 BROADWAY BRUNSWICK HOSPITAL CENTER, INC
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-759-0161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2 HERTER PLACE
-----------------------------------------------------
City | DIX HILLS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11746-0000
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-759-0161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 218742
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------