Basic Information
| Provider Information | |||||||||
| NPI: | 1942881404 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OMADEVUAE | ||||||||
| FirstName: | DIETANURUN | ||||||||
| MiddleName: | BOSE | ||||||||
| NamePrefix: | |||||||||
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| OtherOrganizationName: | |||||||||
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| OtherLastName: | OMADEVUAE | ||||||||
| OtherFirstName: | DIETANURUN | ||||||||
| OtherMiddleName: | BOSE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 300 INTERNATIONAL PKWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327465028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666100580 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10920 MOSS PARK RD | ||||||||
| Address2: | |||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328326086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079304339 | ||||||||
| FaxNumber: | 4077451326 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2021 | ||||||||
| LastUpdateDate: | 04/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.