Provider Demographics
NPI:1245385962
Name:OGLESBY, JOHN SUTHERLAND (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:SUTHERLAND
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 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-2099
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:
Practice Address - Street 1:1701 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2077
Practice Address - Country:US
Practice Address - Phone:360-426-2653
Practice Address - Fax:888-985-0681
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD214999207V00000X
UT373956-1205207V00000X
WI44235207V00000X
WAMD00047723207V00000X
TN63060207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34178400Medicaid