Provider Demographics
NPI:1124438304
Name:IZEVBIZUA, OSAHON
Entity type:Individual
Prefix:
First Name:OSAHON
Middle Name:
Last Name:IZEVBIZUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PECONIC ST APT 96A
Mailing Address - Street 2:
Mailing Address - City:RONKONKOMA
Mailing Address - State:NY
Mailing Address - Zip Code:11779-7124
Mailing Address - Country:US
Mailing Address - Phone:631-377-9211
Mailing Address - Fax:
Practice Address - Street 1:500 PECONIC ST APT 96A
Practice Address - Street 2:
Practice Address - City:RONKONKOMA
Practice Address - State:NY
Practice Address - Zip Code:11779-7124
Practice Address - Country:US
Practice Address - Phone:631-377-9211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-28
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker