Healthcare Provider Details

I. General information

NPI: 1548526494
Provider Name (Legal Business Name): OMOLADE OGUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OMOLADE AKINSANYA M.D.

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 10/01/2021
Certification Date: 10/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4676 ADMIRALTY WAY FL 4
MARINA DEL REY CA
90292-6601
US

IV. Provider business mailing address

PO BOX 20471
BAKERSFIELD CA
93390-0471
US

V. Phone/Fax

Practice location:
  • Phone: 310-306-6966
  • Fax:
Mailing address:
  • Phone: 310-465-8448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA121040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: