Provider Demographics
NPI:1154416691
Name:ODOOM, EBENEZER KOFI BENTUM (MD)
Entity type:Individual
Prefix:
First Name:EBENEZER
Middle Name:KOFI BENTUM
Last Name:ODOOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1010 NORTHERN BLVD STE 328
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5329
Mailing Address - Country:US
Mailing Address - Phone:516-233-2484
Mailing Address - Fax:516-304-5850
Practice Address - Street 1:21530 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11427-1831
Practice Address - Country:US
Practice Address - Phone:718-740-1701
Practice Address - Fax:718-740-1901
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY230787207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02711CMedicare PIN
NYI03864Medicare UPIN
NY00669Medicare PIN