Provider Demographics
NPI:1619473261
Name:OGOO, MAUDELINE
Entity Type:Individual
Prefix:
First Name:MAUDELINE
Middle Name:
Last Name:OGOO
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 1:523 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46013-4021
Mailing Address - Country:US
Mailing Address - Phone:765-642-7246
Mailing Address - Fax:765-642-6986
Practice Address - Street 1:523 W 38TH ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46013-4021
Practice Address - Country:US
Practice Address - Phone:765-642-7246
Practice Address - Fax:765-642-6986
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2018-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003027A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor