Healthcare Provider Details

I. General information

NPI: 1376561571
Provider Name (Legal Business Name): SUSANNAH OGUNWO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7300 S RAEFORD RD
FAYETTEVILLE NC
28304-6162
US

IV. Provider business mailing address

7300 S RAEFORD RD
FAYETTEVILLE NC
28304-6162
US

V. Phone/Fax

Practice location:
  • Phone: 910-488-2120
  • Fax:
Mailing address:
  • Phone: 910-488-2120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2006-01059
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2006-01059
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: