Healthcare Provider Details

I. General information

NPI: 1194849901
Provider Name (Legal Business Name): OLUSOLA OGUNDIPE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 ROOSEVELT RD
VALPARAISO IN
46383-0970
US

IV. Provider business mailing address

342 E 109TH AVE
CROWN POINT IN
46307-8693
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-1620
  • Fax: 219-477-4565
Mailing address:
  • Phone: 219-310-2550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number10165962A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: