=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265527493
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. FELIX OSABOHIEN ODUWA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2006
-----------------------------------------------------
Last Update Date | 05/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1729 BURRSTONE RD
-----------------------------------------------------
City | NEW HARTFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13413-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-435-6633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1729 BURRSTONE RD
-----------------------------------------------------
City | NEW HARTFORD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13413-1001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 912-435-6633
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 285467
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------