Healthcare Provider Details

I. General information

NPI: 1275833295
Provider Name (Legal Business Name): OLUGBENGA A OGUNSANYA DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9050 PERIDOT PKWY SUITE E
STOCKBRIDGE GA
30281-9417
US

IV. Provider business mailing address

127 LAKE TER
MCDONOUGH GA
30253-6546
US

V. Phone/Fax

Practice location:
  • Phone: 770-474-0540
  • Fax: 770-507-0506
Mailing address:
  • Phone: 678-793-7887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT010118
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: