Healthcare Provider Details

I. General information

NPI: 1790647675
Provider Name (Legal Business Name): ANTHONY OGUOGHO PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2025
Last Update Date: 11/29/2025
Certification Date: 11/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12120 PLUM ORCHARD DR
SILVER SPRING MD
20904-7820
US

IV. Provider business mailing address

3219 WINTERBOURNE DR
UPPER MARLBORO MD
20774-9083
US

V. Phone/Fax

Practice location:
  • Phone: 310-586-0900
  • Fax:
Mailing address:
  • Phone: 310-586-0900
  • Fax: 310-586-0900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP200004844
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: