Provider Demographics
NPI:1679652366
Name:BOMA, NELLIE SHURI (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:NELLIE
Middle Name:SHURI
Last Name:BOMA
Suffix:
Gender:F
Credentials:MD, MPH
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Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1225 GERARD AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10452-8001
Mailing Address - Country:US
Mailing Address - Phone:718-960-2793
Mailing Address - Fax:718-960-2619
Practice Address - Street 1:1225 GERARD AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10452-8001
Practice Address - Country:US
Practice Address - Phone:718-960-2793
Practice Address - Fax:718-960-2619
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY204104-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG61067Medicare UPIN