Provider Demographics
NPI:1124637830
Name:FAMUYIDE, OLUWAGBENGA A
Entity type:Individual
Prefix:MR
First Name:OLUWAGBENGA
Middle Name:A
Last Name:FAMUYIDE
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 1:3528 CLAY PL NE APT 4
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20019-2656
Mailing Address - Country:US
Mailing Address - Phone:336-684-7553
Mailing Address - Fax:
Practice Address - Street 1:3528 CLAY PL NE APT 4
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20019-2656
Practice Address - Country:US
Practice Address - Phone:336-684-7553
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA15325374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty