Provider Demographics
NPI:1720669245
Name:OGUNYOYE, MOSES
Entity Type:Individual
Prefix:
First Name:MOSES
Middle Name:
Last Name:OGUNYOYE
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 1:1508 ROBERT LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20774-5652
Mailing Address - Country:US
Mailing Address - Phone:301-928-8837
Mailing Address - Fax:
Practice Address - Street 1:12158 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:MITCHELLVILLE
Practice Address - State:MD
Practice Address - Zip Code:20721-1932
Practice Address - Country:US
Practice Address - Phone:301-430-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-16
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD41201651600Medicaid