Provider Demographics
NPI:1558036103
Name:BALOGUN, OLUWANIFEMI TOLULASE (MD)
Entity Type:Individual
Prefix:
First Name:OLUWANIFEMI
Middle Name:TOLULASE
Last Name:BALOGUN
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 1:1320 W SOMERVILLE AVE APT SUITE219
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-2968
Mailing Address - Country:US
Mailing Address - Phone:484-724-3964
Mailing Address - Fax:
Practice Address - Street 1:5501 OLD YORK RD STE 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3098
Practice Address - Country:US
Practice Address - Phone:484-724-3964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-14
Last Update Date:2021-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program