Provider Demographics
NPI:1821769092
Name:OBEGOLU, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:OBEGOLU
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 1:110 BENMORE DR
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94542-7936
Mailing Address - Country:US
Mailing Address - Phone:415-517-9247
Mailing Address - Fax:
Practice Address - Street 1:110 BENMORE DR
Practice Address - Street 2:
Practice Address - City:HAYWARD
Practice Address - State:CA
Practice Address - Zip Code:94542-7936
Practice Address - Country:US
Practice Address - Phone:415-517-9247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-27
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA556373163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministratorGroup - Single Specialty