Provider Demographics
NPI:1982340766
Name:TERRY, OLUTUNGIE
Entity Type:Individual
Prefix:
First Name:OLUTUNGIE
Middle Name:
Last Name:TERRY
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 1:128 E LEATRICE LN APT 3
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92802-4248
Mailing Address - Country:US
Mailing Address - Phone:661-435-1641
Mailing Address - Fax:
Practice Address - Street 1:128 E LEATRICE LN APT 3
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92802-4248
Practice Address - Country:US
Practice Address - Phone:661-435-1641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-05
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program