Basic Information
| Provider Information | |||||||||
| NPI: | 1841425964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OOMMEN | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR STE 1420 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026233017 | ||||||||
| FaxNumber: | 3022669960 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 HYGEIA DR STE 1420 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026233017 | ||||||||
| FaxNumber: | 3022669960 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2009 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD448588 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0600X | MD448588 | PA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | C1-0024424 | DE | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 102930083 | 05 | PA | MEDICAID |