Provider Demographics
NPI:1275091258
Name:OGUNYELE, IDRIS O
Entity Type:Individual
Prefix:
First Name:IDRIS
Middle Name:O
Last Name:OGUNYELE
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 1:5715 SHORE FRONT PKWY APT 502
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1841
Mailing Address - Country:US
Mailing Address - Phone:347-666-7511
Mailing Address - Fax:
Practice Address - Street 1:5715 SHORE FRONT PKWY APT 502
Practice Address - Street 2:
Practice Address - City:ARVERNE
Practice Address - State:NY
Practice Address - Zip Code:11692-1841
Practice Address - Country:US
Practice Address - Phone:347-666-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-07
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst