Healthcare Provider Details

I. General information

NPI: 1922530880
Provider Name (Legal Business Name): AYO OGUNTOYE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date: 06/04/2018
Reactivation Date: 10/05/2021

III. Provider practice location address

375 SEGUINE AVE
STATEN ISLAND NY
10309-3932
US

IV. Provider business mailing address

PO BOX 612
NEW YORK NY
10027-0612
US

V. Phone/Fax

Practice location:
  • Phone: 718-226-2000
  • Fax:
Mailing address:
  • Phone: 203-449-4044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberF432151-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: