Provider Demographics
NPI:1386915387
Name:OMADESALA PSYCHIATRIC SERVICES, LLC
Entity type:Organization
Organization Name:OMADESALA PSYCHIATRIC SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:D
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-365-0448
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:ROOSEVELT
Mailing Address - State:NJ
Mailing Address - Zip Code:08555-0009
Mailing Address - Country:US
Mailing Address - Phone:609-301-5089
Mailing Address - Fax:831-303-5089
Practice Address - Street 1:285 DURHAM AVE STE 2A
Practice Address - Street 2:BUILDING 6
Practice Address - City:SOUTH PLAINFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07080-2546
Practice Address - Country:US
Practice Address - Phone:908-548-8533
Practice Address - Fax:908-548-8532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-23
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9760812OtherAETNA