Provider Demographics
NPI:1356332845
Name:BALOGUN, ABIODUN FATIMA (MD)
Entity Type:Individual
Prefix:
First Name:ABIODUN
Middle Name:FATIMA
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1921 STONECIPHER BLVD
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820
Mailing Address - Country:US
Mailing Address - Phone:580-436-3980
Mailing Address - Fax:580-421-6283
Practice Address - Street 1:1921 STONECIPHER BLVD
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820
Practice Address - Country:US
Practice Address - Phone:580-436-3980
Practice Address - Fax:580-421-6283
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS19061208000000X
GA054060208000000X
OK31162208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08437778Medicaid
MS00026893Medicaid
LA1994596Medicaid