Provider Demographics
NPI:1720126600
Name:OGUNWALE, BEN O (MD)
Entity Type:Individual
Prefix:
First Name:BEN
Middle Name:O
Last Name:OGUNWALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 LILLINGTON AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28204-3189
Mailing Address - Country:US
Mailing Address - Phone:704-362-4403
Mailing Address - Fax:704-362-4405
Practice Address - Street 1:320 LILLINGTON AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3189
Practice Address - Country:US
Practice Address - Phone:704-362-4403
Practice Address - Fax:704-362-4405
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35-082786207R00000X
NC2007-01133207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC59-12694Medicaid
OHH93091Medicare UPIN