Provider Demographics
NPI:1235131806
Name:SERRANO, OLUWAGBENGA (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUWAGBENGA
Middle Name:
Last Name:SERRANO
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 1:1813 WILLOW ST STE 5B
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4279
Mailing Address - Country:US
Mailing Address - Phone:812-882-2703
Mailing Address - Fax:812-882-2760
Practice Address - Street 1:1813 WILLOW ST STE 5B
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-4279
Practice Address - Country:US
Practice Address - Phone:812-882-2703
Practice Address - Fax:812-882-2760
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2160261207RG0100X
SD8773207RG0100X
IN01049379A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201207410Medicaid
IN000001180285OtherANTHEM
IN258190110OtherMEDICARE
AZ639396Medicaid