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NPI Code Detail

MEDICARE: DR. YETUNDE O BALOGUN M.D.

MEDICARE: DR. YETUNDE O BALOGUN M.D.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
12086S0129XVascular Surgery PhysicianV8935TX
2208600000XSurgery PhysicianMT200039PA

General Provider Information

NPI Number : 1306129713
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. YETUNDE O BALOGUN M.D.
Provider Business Mailing Address
First Line : 3401 N BROAD ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19140-5103
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3401 N BROAD ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19140-5103
Country : US
Telephone Number : 267-294-9265
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/21/2011
Last Update Date : 03/24/2026

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