Provider Demographics
NPI:1164242848
Name:UWAGBOE, JOHNSON O
Entity type:Individual
Prefix:
First Name:JOHNSON
Middle Name:O
Last Name:UWAGBOE
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 1:999 HIDDEN LAKE DR APT 3F
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-1180
Mailing Address - Country:US
Mailing Address - Phone:786-512-8256
Mailing Address - Fax:
Practice Address - Street 1:999 HIDDEN LAKE DR APT 3F
Practice Address - Street 2:
Practice Address - City:NORTH BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08902-1180
Practice Address - Country:US
Practice Address - Phone:786-512-8256
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service