Provider Demographics
NPI:1518276245
Name:OGBOLU, EMMANUEL I
Entity Type:Individual
Prefix:MR
First Name:EMMANUEL
Middle Name:I
Last Name:OGBOLU
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 1:11615 FOREST CENTRAL DR
Mailing Address - Street 2:SUITE 321
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-5905
Mailing Address - Country:US
Mailing Address - Phone:214-342-8888
Mailing Address - Fax:214-342-9999
Practice Address - Street 1:11615 FOREST CENTRAL DR
Practice Address - Street 2:SUITE 321
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-5905
Practice Address - Country:US
Practice Address - Phone:214-342-8888
Practice Address - Fax:214-342-9999
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-29
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX6581430001Medicare NSC