=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396945622
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. DOROTHY NENE OGUNDU, MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2007
-----------------------------------------------------
Last Update Date | 07/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11455 FARMERS BLVD 1ST FLOOR
-----------------------------------------------------
City | SAINT ALBANS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11412-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-776-9699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11455 FARMERS BLVD 1ST FLOOR
-----------------------------------------------------
City | SAINT ALBANS
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11412-2740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-776-9699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DOROTHY N OGUNDU
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 718-776-9699
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number | 167797-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207VG0400X
-----------------------------------------------------
Taxonomy Name | Gynecology Physician
-----------------------------------------------------
License Number | 167797-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------