Provider Demographics
NPI:1760254221
Name:ORIAIFO, ODIANOSEN
Entity type:Individual
Prefix:
First Name:ODIANOSEN
Middle Name:
Last Name:ORIAIFO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57 BANK ST APT 1718
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10606-2069
Mailing Address - Country:US
Mailing Address - Phone:410-491-5396
Mailing Address - Fax:
Practice Address - Street 1:12 TIBBITS AVE
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10606-2438
Practice Address - Country:US
Practice Address - Phone:914-287-7200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-26
Last Update Date:2025-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant