Provider Demographics
NPI:1245440304
Name:ELEGBE, OLUGBEMI O (MD)
Entity type:Individual
Prefix:
First Name:OLUGBEMI
Middle Name:O
Last Name:ELEGBE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4900 PARK AVE
Mailing Address - Street 2:STE. 304
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72903-1478
Mailing Address - Country:US
Mailing Address - Phone:479-478-6174
Mailing Address - Fax:479-314-1194
Practice Address - Street 1:501 W RIVER ST
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AR
Practice Address - Zip Code:72949-3127
Practice Address - Country:US
Practice Address - Phone:479-667-4138
Practice Address - Fax:479-667-9778
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ3177207P00000X
ARE-6310207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA07833Medicaid