Provider Demographics
NPI:1669640082
Name:IBRAHIM-BALOGUN, LAWAL ABIODUN
Entity Type:Individual
Prefix:
First Name:LAWAL
Middle Name:ABIODUN
Last Name:IBRAHIM-BALOGUN
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 1:1525 N D ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92405-4722
Mailing Address - Country:US
Mailing Address - Phone:909-386-3657
Mailing Address - Fax:909-388-9173
Practice Address - Street 1:1525 N D ST
Practice Address - Street 2:SUITE 14
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92405-4722
Practice Address - Country:US
Practice Address - Phone:909-386-3657
Practice Address - Fax:909-388-9173
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-19
Last Update Date:2011-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48762332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6100210001Medicare NSC