MEDICARE: DR. KENNEDY ONOME OMONUWA M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	245036	NY

General Provider Information

NPI Number	:	1730389172
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNEDY ONOME OMONUWA M.D

Provider Business Mailing Address
First Line	:	410 LAKEVILLE RD STE 107
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1102
Country	:	US
Telephone Number	:	516-465-5400
Fax Number	:	516-465-5454

Provider Business Practice Location Address
First Line	:	410 LAKEVILLE RD STE 107
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1102
Country	:	US
Telephone Number	:	516-465-5400
Fax Number	:	516-465-5454

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/24/2007
Last Update Date	:	07/24/2007

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