Healthcare Provider Details

I. General information

NPI: 1679746713
Provider Name (Legal Business Name): OLUSEGUN Z. SALAKO M.D. INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/09/2008
Last Update Date: 11/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W ANAHEIM ST
WILMINGTON CA
90744-4418
US

IV. Provider business mailing address

215 W ANAHEIM ST
WILMINGTON CA
90744-4418
US

V. Phone/Fax

Practice location:
  • Phone: 310-816-3111
  • Fax: 310-816-3116
Mailing address:
  • Phone: 310-816-3111
  • Fax: 310-816-3116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG54804
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA83572
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberG67118
License Number StateCA

VIII. Authorized Official

Name: DR. THECLA N. MGBOJIRIKWE
Title or Position: PEDIATRIC SPECIALIST/MEDICAL DIRECT
Credential: M.D.
Phone: 562-218-6264