Healthcare Provider Details

I. General information

NPI: 1548880222
Provider Name (Legal Business Name): OLUSHOLA OGUNLARI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 04/22/2020
Certification Date: 04/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 100613
PALM BAY FL
32910-0613
US

V. Phone/Fax

Practice location:
  • Phone: 904-244-0411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36151
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: