Provider Demographics
NPI:1851072474
Name:SOGBAMU, OLUGBENGA DAVID
Entity Type:Individual
Prefix:
First Name:OLUGBENGA
Middle Name:DAVID
Last Name:SOGBAMU
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 1:3661 DEATON TRL
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-1110
Mailing Address - Country:US
Mailing Address - Phone:334-612-8501
Mailing Address - Fax:
Practice Address - Street 1:3661 DEATON TRL
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-1110
Practice Address - Country:US
Practice Address - Phone:334-612-8501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN277331363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health