Healthcare Provider Details

I. General information

NPI: 1366951113
Provider Name (Legal Business Name): KOLA OGUNDIPE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1731 STEARNS DR
LOS ANGELES CA
90035-4627
US

IV. Provider business mailing address

1731 STEARNS DR
LOS ANGELES CA
90035-4627
US

V. Phone/Fax

Practice location:
  • Phone: 310-404-4829
  • Fax: 323-375-1771
Mailing address:
  • Phone: 310-404-4829
  • Fax: 323-375-1771

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number542332
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: