Healthcare Provider Details

I. General information

NPI: 1619132537
Provider Name (Legal Business Name): OREOLUWA I OGUNYEMI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 12/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6880 PALM AVE
SEBASTOPOL CA
95472-4270
US

IV. Provider business mailing address

6880 PALM AVE
SEBASTOPOL CA
95472-4270
US

V. Phone/Fax

Practice location:
  • Phone: 707-823-7628
  • Fax: 707-823-1521
Mailing address:
  • Phone: 707-823-7628
  • Fax: 707-823-1521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberA126139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: