Provider Demographics
NPI:1194849901
Name:OGUNDIPE, OLUSOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUSOLA
Middle Name:
Last Name:OGUNDIPE
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 1:342 E 109TH AVE
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-8693
Mailing Address - Country:US
Mailing Address - Phone:219-310-2550
Mailing Address - Fax:
Practice Address - Street 1:2600 ROOSEVELT RD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-0970
Practice Address - Country:US
Practice Address - Phone:219-464-1620
Practice Address - Fax:219-477-4565
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10165962A207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01065962AOtherLICENSE
IN200922610Medicaid
IL36-110404OtherSTATE LICENSE NUMBER
IL36-110404OtherSTATE LICENSE NUMBER
IN01065962AOtherLICENSE