Provider Demographics
NPI:1700439536
Name:GEORGE, OGO
Entity Type:Individual
Prefix:
First Name:OGO
Middle Name:
Last Name:GEORGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 WASHINGTON ST STE 3
Mailing Address - Street 2:
Mailing Address - City:STOUGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02072-2971
Mailing Address - Country:US
Mailing Address - Phone:508-345-5324
Mailing Address - Fax:781-986-4616
Practice Address - Street 1:810 WASHINGTON ST STE 3
Practice Address - Street 2:
Practice Address - City:STOUGHTON
Practice Address - State:MA
Practice Address - Zip Code:02072-2971
Practice Address - Country:US
Practice Address - Phone:508-345-5324
Practice Address - Fax:781-986-4616
Is Sole Proprietor?:No
Enumeration Date:2019-07-21
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA230084363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110158499AMedicaid