Provider Demographics
NPI:1619088812
Name:OJUGBELI, DIANE SOPHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:SOPHIA
Last Name:OJUGBELI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1004 GILL ST
Mailing Address - Street 2:
Mailing Address - City:CHITTENANGO
Mailing Address - State:NY
Mailing Address - Zip Code:13037-0001
Mailing Address - Country:US
Mailing Address - Phone:315-687-7319
Mailing Address - Fax:
Practice Address - Street 1:304 GENESEE ST
Practice Address - Street 2:
Practice Address - City:CHITTENANGO
Practice Address - State:NY
Practice Address - Zip Code:13037-0001
Practice Address - Country:US
Practice Address - Phone:315-687-6467
Practice Address - Fax:315-687-6041
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219809-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02105113Medicaid
H32400Medicare UPIN
CC4574Medicare ID - Type Unspecified