Healthcare Provider Details

I. General information

NPI: 1194497131
Provider Name (Legal Business Name): DR. OLUFEMI OLUGBOYEGA OGUNGBE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

1512 VISTA VERDE DR
ESCONDIDO CA
92026-1504
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6400
  • Fax:
Mailing address:
  • Phone: 619-607-1790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001580
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024187349
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: