Provider Demographics
NPI:1932577137
Name:OPUTA, AGHOGHO H
Entity Type:Individual
Prefix:
First Name:AGHOGHO
Middle Name:H
Last Name:OPUTA
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 1:4361 BRUNER AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1361 COLLEGE AVE
Practice Address - Street 2:APT 5B
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10456-1505
Practice Address - Country:US
Practice Address - Phone:917-495-6551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-04
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY321971-1164W00000X
NY770146163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse