Provider Demographics
NPI:1619201407
Name:BALOGUN-VICTOR, TIMOTHY OLAWALE
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:OLAWALE
Last Name:BALOGUN-VICTOR
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 1:151 S BISHOP AVE
Mailing Address - Street 2:K20
Mailing Address - City:SECANE
Mailing Address - State:PA
Mailing Address - Zip Code:19018-1971
Mailing Address - Country:US
Mailing Address - Phone:610-864-5660
Mailing Address - Fax:
Practice Address - Street 1:151 S BISHOP AVE
Practice Address - Street 2:K20
Practice Address - City:SECANE
Practice Address - State:PA
Practice Address - Zip Code:19018-1971
Practice Address - Country:US
Practice Address - Phone:610-864-5660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program