Healthcare Provider Details

I. General information

NPI: 1720604986
Provider Name (Legal Business Name): MATHIAS OMON OLOGBOSELE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2020
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PASTERN TER
BURLINGTON NJ
08016-4296
US

IV. Provider business mailing address

615 S 19TH ST
NEWARK NJ
07103-1116
US

V. Phone/Fax

Practice location:
  • Phone: 973-964-4720
  • Fax:
Mailing address:
  • Phone: 973-964-4720
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ01039100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: