Basic Information
| Provider Information | |||||||||
| NPI: | 1275560492 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGUWA | ||||||||
| FirstName: | MRIDASIM | ||||||||
| MiddleName: | O | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S BEDFORD RD | ||||||||
| Address2: | CAREMOUNT MEDICAL PC | ||||||||
| City: | MOUNT KISCO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105493446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142411050 | ||||||||
| FaxNumber: | 9142421516 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 COLUMBIA ST | ||||||||
| Address2: | |||||||||
| City: | POUGHKEEPSIE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 126013906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452315600 | ||||||||
| FaxNumber: | 8452315654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2006 | ||||||||
| LastUpdateDate: | 11/15/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 236372 | NY | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 2680046 | 05 | NY | MEDICAID |