Provider Demographics
NPI:1275602963
Name:OGUNFOWORA, OLUSEGUN (MD)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:
Last Name:OGUNFOWORA
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 1:529 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3645
Mailing Address - Country:US
Mailing Address - Phone:718-327-7307
Mailing Address - Fax:
Practice Address - Street 1:529 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3645
Practice Address - Country:US
Practice Address - Phone:718-327-7307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2016-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY206115-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01775084Medicaid
NYG28420Medicare UPIN
NY01775084Medicaid