Provider Demographics
NPI:1013328293
Name:OGLESBY, MATTHEW WAYNE (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:WAYNE
Last Name:OGLESBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 REGENCY PARK DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-6649
Mailing Address - Country:US
Mailing Address - Phone:404-843-3323
Mailing Address - Fax:404-574-5944
Practice Address - Street 1:3421 VILLA LN STE 2B
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-3060
Practice Address - Country:US
Practice Address - Phone:707-255-5454
Practice Address - Fax:707-255-5411
Is Sole Proprietor?:No
Enumeration Date:2014-05-09
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA88009208100000X
CA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation