Provider Demographics
NPI:1003227745
Name:OGUNDERE, ADETOMIWA (MD)
Entity Type:Individual
Prefix:
First Name:ADETOMIWA
Middle Name:
Last Name:OGUNDERE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 4TH ST
Mailing Address - Street 2:MS 9410
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-0002
Mailing Address - Country:US
Mailing Address - Phone:806-743-6840
Mailing Address - Fax:
Practice Address - Street 1:701 W 5TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79763-4206
Practice Address - Country:US
Practice Address - Phone:432-703-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-15
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXR8447207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program