Provider Demographics
NPI:1558089342
Name:KONIGBAGBE, OLUWOLE OLUYINKA OLUYEMI (MBBS)
Entity Type:Individual
Prefix:DR
First Name:OLUWOLE
Middle Name:OLUYINKA OLUYEMI
Last Name:KONIGBAGBE
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 NEWBURY CT
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-3287
Mailing Address - Country:US
Mailing Address - Phone:860-265-9619
Mailing Address - Fax:
Practice Address - Street 1:140 SAINT EDWARDS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3904
Practice Address - Country:US
Practice Address - Phone:718-858-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP115301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty