Provider Demographics
NPI:1174729784
Name:IDAHOSA, OSAMUDIAMEN (MD)
Entity type:Individual
Prefix:
First Name:OSAMUDIAMEN
Middle Name:
Last Name:IDAHOSA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 CHESTNUT LN
Mailing Address - Street 2:
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454-1303
Mailing Address - Country:US
Mailing Address - Phone:267-481-4905
Mailing Address - Fax:
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015-1000
Practice Address - Country:US
Practice Address - Phone:484-526-3285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432354207RC0200X
PAMT183290207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1754246OtherAETNA - HMO
NJ338072OtherAMERIGROUP
NJ91002708400OtherAMERICHOICE
NJP00620721OtherRR MEDICARE
NJ9031110OtherAENTA - PPO
NJ0144436Medicaid
NJ91002708400OtherAMERICHOICE
NJ338072OtherAMERIGROUP
NJ0144436Medicaid