Provider Demographics
NPI:1184821704
Name:BALOGUN, OLA ADEBAYO
Entity Type:Individual
Prefix:MR
First Name:OLA
Middle Name:ADEBAYO
Last Name:BALOGUN
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 1:2116 SPRING FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-7533
Mailing Address - Country:US
Mailing Address - Phone:919-271-0517
Mailing Address - Fax:800-608-8907
Practice Address - Street 1:1307 E MILLBROOK RD STE C106
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-5476
Practice Address - Country:US
Practice Address - Phone:919-271-0517
Practice Address - Fax:800-608-8907
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies