Healthcare Provider Details

I. General information

NPI: 1164242848
Provider Name (Legal Business Name): JOHNSON O UWAGBOE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 HIDDEN LAKE DR APT 3F
NORTH BRUNSWICK NJ
08902-1180
US

IV. Provider business mailing address

999 HIDDEN LAKE DR APT 3F
NORTH BRUNSWICK NJ
08902-1180
US

V. Phone/Fax

Practice location:
  • Phone: 786-512-8256
  • Fax:
Mailing address:
  • Phone: 786-512-8256
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: