Provider Demographics
NPI:1295828127
Name:OGUNWANDE, CLEMENT ADEDEJO (DO)
Entity Type:Individual
Prefix:
First Name:CLEMENT
Middle Name:ADEDEJO
Last Name:OGUNWANDE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N. BROOM STREET
Mailing Address - Street 2:SUITE 109
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19802
Mailing Address - Country:US
Mailing Address - Phone:302-762-4545
Mailing Address - Fax:302-762-9086
Practice Address - Street 1:1800 N. BROOM STREET
Practice Address - Street 2:SUITE 109
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19802
Practice Address - Country:US
Practice Address - Phone:302-762-4545
Practice Address - Fax:302-762-9086
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0004996207Q00000X
DEC20004996207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000981603Medicaid
DEG01637Medicare PIN
DEY18409Medicare UPIN
DE0000981603Medicaid