Provider Demographics
NPI:1861989550
Name:OMEH, DEMIAN JIDEOFOR (MD)
Entity type:Individual
Prefix:
First Name:DEMIAN
Middle Name:JIDEOFOR
Last Name:OMEH
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 1:2201 HEMPSTEAD TURNPIKE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11554
Mailing Address - Country:US
Mailing Address - Phone:516-572-6504
Mailing Address - Fax:516-572-5609
Practice Address - Street 1:2201 HEMPSTEAD TURNPIKE
Practice Address - Street 2:
Practice Address - City:EAST MEADOW
Practice Address - State:NY
Practice Address - Zip Code:11554
Practice Address - Country:US
Practice Address - Phone:516-572-6504
Practice Address - Fax:516-572-5609
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2021-09-21
Deactivation Date:2018-11-28
Deactivation Code:
Reactivation Date:2018-12-18
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC2086250207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program