Healthcare Provider Details

I. General information

NPI: 1225723638
Provider Name (Legal Business Name): MARY OGUNDARE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2023
Last Update Date: 04/11/2023
Certification Date: 04/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 E 242ND ST
BRONX NY
10470-1202
US

IV. Provider business mailing address

1050 E 215TH ST
BRONX NY
10469-1307
US

V. Phone/Fax

Practice location:
  • Phone: 646-671-2807
  • Fax:
Mailing address:
  • Phone: 646-671-2807
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number349457
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: