Provider Demographics
NPI:1619942695
Name:OGUNTUASE, EBENEZER (RPT)
Entity Type:Individual
Prefix:MR
First Name:EBENEZER
Middle Name:
Last Name:OGUNTUASE
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 E LANDIS AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-8004
Mailing Address - Country:US
Mailing Address - Phone:856-794-2100
Mailing Address - Fax:856-794-2120
Practice Address - Street 1:611 E LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-8004
Practice Address - Country:US
Practice Address - Phone:856-794-2100
Practice Address - Fax:856-794-2120
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00598500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2115735000OtherAMERIHEALTH
PA532743OtherBLUE SHIELD OF PA
NJ1000146OtherUS HEALTHCARE
NJP00040938OtherRAILROAD MEDICARE
NJ5294643OtherAETNA US HEALTHCARE
NJP00040938OtherRAILROAD MEDICARE