Provider Demographics
NPI:1083615348
Name:MOGBO, SOLOMON C (MD)
Entity Type:Individual
Prefix:DR
First Name:SOLOMON
Middle Name:C
Last Name:MOGBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1401 KANIS PARK DR
Mailing Address - Street 2:STE 200
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-4571
Mailing Address - Country:US
Mailing Address - Phone:501-537-4590
Mailing Address - Fax:501-537-4591
Practice Address - Street 1:1401 KANIS PARK DR
Practice Address - Street 2:STE 200
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-4571
Practice Address - Country:US
Practice Address - Phone:501-537-4590
Practice Address - Fax:501-537-4591
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ARE1875207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR145707001Medicaid
AR912187095OtherTAX IDENTIFCATION
AR5L622Medicare ID - Type Unspecified
AR145707001Medicaid