Healthcare Provider Details

I. General information

NPI: 1659664746
Provider Name (Legal Business Name): JAMES O OGEDEGBE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2011
Last Update Date: 05/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 LOVELAND BLVD
PORT CHARLOTTE FL
33980-1802
US

IV. Provider business mailing address

514 E GRACE ST
PUNTA GORDA FL
33950-6121
US

V. Phone/Fax

Practice location:
  • Phone: 941-624-7200
  • Fax: 941-624-7200
Mailing address:
  • Phone: 941-639-1811
  • Fax: 941-639-0854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: