Healthcare Provider Details

I. General information

NPI: 1053650630
Provider Name (Legal Business Name): CLARENCE O OJO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2013
Last Update Date: 12/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 6TH AVE. N.
ST. CLOUD MN
56303-2735
US

IV. Provider business mailing address

1200 6TH AVE. N.
ST. CLOUD MN
56303-2735
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-3342
  • Fax: 320-252-3501
Mailing address:
  • Phone: 320-252-3342
  • Fax: 320-252-3501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number63732
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: