Healthcare Provider Details

I. General information

NPI: 1912226697
Provider Name (Legal Business Name): OLUFEMI ADEMOLA OGUNDEJI M.D, MPH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2010
Last Update Date: 02/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1006 HIGHLAND AVE BRENTWOOD HOSPITAL
SHREVEPORT LA
71101-4103
US

IV. Provider business mailing address

1006 HIGHLAND AVE BRENTWOOD HOSPITAL
SHREVEPORT LA
71101-4103
US

V. Phone/Fax

Practice location:
  • Phone: 318-222-6226
  • Fax: 318-222-6227
Mailing address:
  • Phone: 318-222-6226
  • Fax: 318-222-6227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberMD207354
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: