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3800 W Broward Blvd Fort Lauderdale FL 33312-1018 | |
| (954) 496-2599 | |
| Not Available |
| Full Name | |
|---|---|
| Speciality | Psychiatry & Neurology |
| Location | 3800 W Broward Blvd, Fort Lauderdale, Florida |
| Authorized Official Name and Position | Henry Odazie (CEO) |
| Authorized Official Contact | 9544962599 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
3800 W Broward Blvd Fort Lauderdale FL 33312-1018 Ph: (954) 496-2599 | 3800 W Broward Blvd Fort Lauderdale FL 33312-1018 Ph: (954) 496-2599 |
| NPI Number | 1215623624 |
|---|---|
| Provider Enumeration Date | 04/18/2023 |
| Last Update Date | 03/20/2024 |
| Certification Date | 03/20/2024 |
| Medicare PECOS PAC ID | 7416315882 |
|---|---|
| Medicare Enrollment ID | O20230615003263 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1215623624 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 2084P0800X | Psychiatry & Neurology - Psychiatry | (* (Not Available)) | Primary |
| 261QM0850X | Clinic/center - Adult Mental Health | (* (Not Available)) | Secondary |
| Provider Name | Henry Odazie |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1740880848 PECOS PAC ID: 4688084296 Enrollment ID: I20201111001171 |
| Provider Name | Chinedu O Okeke |
|---|---|
| Provider Type | Practitioner - General Practice |
| Provider Identifiers | NPI Number: 1942663364 PECOS PAC ID: 6901190230 Enrollment ID: I20211108002519 |
| Provider Name | Ahmed Riaz |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1467959908 PECOS PAC ID: 5395097976 Enrollment ID: I20220713000380 |
| Provider Name | Rajalakshmi Suresh |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1881393304 PECOS PAC ID: 9133580624 Enrollment ID: I20230731004109 |
| Provider Name | Manju Chandran |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1245926146 PECOS PAC ID: 5294181897 Enrollment ID: I20231101003129 |
| Provider Name | Igbinoghodua Jonathan Edomwonyi |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1235978297 PECOS PAC ID: 8022550086 Enrollment ID: I20240605001714 |
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