Healthcare Provider Details

I. General information

NPI: 1497416424
Provider Name (Legal Business Name): OYEWOLE G OGUNNAIKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/03/2022
Last Update Date: 10/08/2025
Certification Date: 10/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1057 POQUONNOCK RD # 6
GROTON CT
06340-6630
US

IV. Provider business mailing address

125 EUGENE ONEILL DR
NEW LONDON CT
06320-6410
US

V. Phone/Fax

Practice location:
  • Phone: 860-984-4552
  • Fax: 844-321-6166
Mailing address:
  • Phone: 956-215-6450
  • Fax: 844-321-6166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1063029
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: