Provider Demographics
NPI:1003413501
Name:ELEGBE, OLUSEGUN
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:
Last Name:ELEGBE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 BROOKFIELD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:NJ
Mailing Address - Zip Code:08527-3897
Mailing Address - Country:US
Mailing Address - Phone:848-525-2348
Mailing Address - Fax:
Practice Address - Street 1:38 BROOKFIELD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:NJ
Practice Address - Zip Code:08527-3897
Practice Address - Country:US
Practice Address - Phone:848-525-2348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide