Provider Demographics
NPI:1497416424
Name:OGUNNAIKE, OYEWOLE G
Entity Type:Individual
Prefix:
First Name:OYEWOLE
Middle Name:G
Last Name:OGUNNAIKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 EUGENE ONEILL DR
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-6410
Mailing Address - Country:US
Mailing Address - Phone:956-215-6450
Mailing Address - Fax:844-321-6166
Practice Address - Street 1:125 EUGENE ONEILL DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-6410
Practice Address - Country:US
Practice Address - Phone:956-215-6450
Practice Address - Fax:844-321-6166
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-03
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1063029363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty