Provider Demographics
NPI:1487809554
Name:OGUNLEYE, SAMMY
Entity type:Individual
Prefix:
First Name:SAMMY
Middle Name:
Last Name:OGUNLEYE
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 1:688 N ARROWHEAD AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92401-1144
Mailing Address - Country:US
Mailing Address - Phone:909-885-2415
Mailing Address - Fax:909-885-2460
Practice Address - Street 1:688 N ARROWHEAD AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92401-1144
Practice Address - Country:US
Practice Address - Phone:909-885-2415
Practice Address - Fax:909-885-2460
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-17
Last Update Date:2008-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46256332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5915030001Medicare NSC