Provider Demographics
NPI:1447912555
Name:OGUNSILE, MATTHEW IDOWU
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:IDOWU
Last Name:OGUNSILE
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 1:216 ASHMORE BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2841
Mailing Address - Country:US
Mailing Address - Phone:186-490-7253
Mailing Address - Fax:
Practice Address - Street 1:216 ASHMORE BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2841
Practice Address - Country:US
Practice Address - Phone:864-907-2537
Practice Address - Fax:864-281-1332
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-06
Last Update Date:2021-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCQIDP171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator