Provider Demographics
NPI:1245440940
Name:GWAN, OFUNDEM ROSE (MD)
Entity type:Individual
Prefix:
First Name:OFUNDEM
Middle Name:ROSE
Last Name:GWAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:282 JOHN WAYNE DR
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-4918
Mailing Address - Country:US
Mailing Address - Phone:337-371-9670
Mailing Address - Fax:318-232-2457
Practice Address - Street 1:1406 S VIENNA ST
Practice Address - Street 2:
Practice Address - City:RUSTON
Practice Address - State:LA
Practice Address - Zip Code:71270-6428
Practice Address - Country:US
Practice Address - Phone:318-232-2456
Practice Address - Fax:318-232-2457
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.203609207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1459330Medicaid