Healthcare Provider Details

I. General information

NPI: 1952626483
Provider Name (Legal Business Name): JUSTIN C. OGBONNA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2010
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

732 HARRISON AVENUE PRESTON 5TH FLOOR
BOSTON MA
02118
US

IV. Provider business mailing address

720 HARRISON AVE DOB 503
BOSTON MA
02118-2371
US

V. Phone/Fax

Practice location:
  • Phone: 617-414-6840
  • Fax: 617-414-6710
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number2387
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: