Healthcare Provider Details

I. General information

NPI: 1366275786
Provider Name (Legal Business Name): HENRY O OWOYELE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2024
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ROBERT WOOD JOHNSON PL
NEW BRUNSWICK NJ
08901-1928
US

IV. Provider business mailing address

2167 HALSEY ST
UNION NJ
07083-5151
US

V. Phone/Fax

Practice location:
  • Phone: 732-414-8421
  • Fax:
Mailing address:
  • Phone: 908-414-0513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number26NJ15100900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: