Provider Demographics
NPI:1720604986
Name:OLOGBOSELE, MATHIAS OMON
Entity Type:Individual
Prefix:
First Name:MATHIAS
Middle Name:OMON
Last Name:OLOGBOSELE
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 1:615 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-1116
Mailing Address - Country:US
Mailing Address - Phone:973-964-4720
Mailing Address - Fax:
Practice Address - Street 1:2 PASTERN TER
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-4296
Practice Address - Country:US
Practice Address - Phone:973-964-4720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-23
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01039100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health