Provider Demographics
NPI:1972036424
Name:OGUNSIAKAN, UDUAK IBANGA
Entity Type:Individual
Prefix:
First Name:UDUAK IBANGA
Middle Name:
Last Name:OGUNSIAKAN
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 1:18902 MONTGOMERY VILLAGE AVE
Mailing Address - Street 2:
Mailing Address - City:GAITHERSBURG
Mailing Address - State:MD
Mailing Address - Zip Code:20886-3724
Mailing Address - Country:US
Mailing Address - Phone:202-361-5080
Mailing Address - Fax:
Practice Address - Street 1:18902 MONTGOMERY VILLAGE AVE
Practice Address - Street 2:
Practice Address - City:GAITHERSBURG
Practice Address - State:MD
Practice Address - Zip Code:20886-3724
Practice Address - Country:US
Practice Address - Phone:202-361-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-11
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR196129163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse