Provider Demographics
NPI:1487120846
Name:OGLESBY, MALORA SHARAY
Entity type:Individual
Prefix:PROF
First Name:MALORA
Middle Name:SHARAY
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:472 CONDUCTOR CT
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:GA
Mailing Address - Zip Code:30549-3242
Mailing Address - Country:US
Mailing Address - Phone:706-201-9809
Mailing Address - Fax:
Practice Address - Street 1:472 CONDUCTOR CT
Practice Address - Street 2:
Practice Address - City:JEFFERSON
Practice Address - State:GA
Practice Address - Zip Code:30549-3242
Practice Address - Country:US
Practice Address - Phone:706-201-9809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-23
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA047612678208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty