Healthcare Provider Details

I. General information

NPI: 1457614646
Provider Name (Legal Business Name): GBOLAHAN O OGUNBAYO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 01/04/2022
Certification Date: 06/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 KINGS DAUGHTERS DR
FRANKFORT KY
40601-6514
US

IV. Provider business mailing address

1425 PORTLAND AVE
ROCHESTER NY
14621-3011
US

V. Phone/Fax

Practice location:
  • Phone: 502-875-5240
  • Fax:
Mailing address:
  • Phone: 585-922-4369
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number48918
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: