Provider Demographics
NPI:1578669743
Name:OGUNMOLA, NICHOLAS A (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:A
Last Name:OGUNMOLA
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-1855
Mailing Address - Fax:682-885-1396
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:817-348-1990
Practice Address - Fax:682-885-1985
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL70822080P0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX140442852Medicaid
TX816427OtherCIGNA PIN
TX133649100OtherFIRSTCARE PIN
TX158394001Medicaid
1750369203OtherGRP NPI NUMBER
TX2335131OtherUHC PIN
TX137345810Medicaid
TX124174OtherSUPERIOR PIN
TX2113894OtherFIRSTHEALTH PIN
TX8G7691OtherBCBSTX IND PIN
TX00U87ZOtherBCBSTX GRP PIN
TX7710465OtherAETNA PIN
TX10010583OtherAMERIGROUP PIN
TX158394002Medicaid
TX2335131OtherUHC PIN
TX816427OtherCIGNA PIN
TX7710465OtherAETNA PIN