Healthcare Provider Details

I. General information

NPI: 1922366350
Provider Name (Legal Business Name): OLUTOYOSI OGUNKUA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2012
Last Update Date: 05/19/2023
Certification Date: 05/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3735 GLENLAKE DR STE 250
CHARLOTTE NC
28208-6866
US

IV. Provider business mailing address

PO BOX 845347
DALLAS TX
75284-5347
US

V. Phone/Fax

Practice location:
  • Phone: 704-749-5800
  • Fax: 704-626-3237
Mailing address:
  • Phone: 469-291-3369
  • Fax: 214-645-0078

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR1429
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2023-01259
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: