Provider Demographics
NPI:1053077156
Name:SASONA, OLUBUNMI B
Entity Type:Individual
Prefix:
First Name:OLUBUNMI
Middle Name:B
Last Name:SASONA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 HOOVER AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3858
Mailing Address - Country:US
Mailing Address - Phone:862-333-6400
Mailing Address - Fax:
Practice Address - Street 1:125 HOOVER AVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3858
Practice Address - Country:US
Practice Address - Phone:862-333-6400
Practice Address - Fax:908-248-8234
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ123172V00000X
172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNONEMedicaid