Basic Information
| Provider Information | |||||||||
| NPI: | 1861989550 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMEH | ||||||||
| FirstName: | DEMIAN | ||||||||
| MiddleName: | JIDEOFOR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2201 HEMPSTEAD TURNPIKE | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726504 | ||||||||
| FaxNumber: | 5165725609 | ||||||||
| Practice Location | |||||||||
| Address1: | 2201 HEMPSTEAD TURNPIKE | ||||||||
| Address2: | |||||||||
| City: | EAST MEADOW | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165726504 | ||||||||
| FaxNumber: | 5165725609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/18/2018 | ||||||||
| LastUpdateDate: | 09/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 11/28/2018 | ||||||||
| NPIReactivationDate: | 12/18/2018 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 2086250 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.