Provider Demographics
NPI:1093940918
Name:HOGAN, OMODELE IBITOLA (MD)
Entity Type:Individual
Prefix:
First Name:OMODELE
Middle Name:IBITOLA
Last Name:HOGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 PLAINSBORO RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PLAINSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08536-1915
Mailing Address - Country:US
Mailing Address - Phone:609-853-7272
Mailing Address - Fax:609-853-7245
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-5301
Practice Address - Country:US
Practice Address - Phone:570-271-6028
Practice Address - Fax:570-271-5845
Is Sole Proprietor?:No
Enumeration Date:2009-05-20
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL13694207R00000X
NJ25MA11280500207RE0101X
FLME119257207RE0101X
PAMD465107207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013079700Medicaid