Provider Demographics
NPI:1366149163
Name:NDOH, IDARA
Entity type:Individual
Prefix:
First Name:IDARA
Middle Name:
Last Name:NDOH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 REMOUNT RD
Mailing Address - Street 2:SUITE C1 #568
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203
Mailing Address - Country:US
Mailing Address - Phone:850-545-9063
Mailing Address - Fax:
Practice Address - Street 1:1600 SARNO RD STE 119J
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4938
Practice Address - Country:US
Practice Address - Phone:321-414-2248
Practice Address - Fax:877-515-0334
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-13
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1720617335OtherNPI