Healthcare Provider Details

I. General information

NPI: 1033199211
Provider Name (Legal Business Name): AYO OGUNLUSI MCD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

782 KLONDIKE AVE
STATEN ISLAND NY
10314-4824
US

IV. Provider business mailing address

782 KLONDIKE AVE
STATEN ISLAND NY
10314-4824
US

V. Phone/Fax

Practice location:
  • Phone: 718-982-5124
  • Fax: 718-982-0494
Mailing address:
  • Phone: 718-982-5124
  • Fax: 718-982-0494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number001496
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: