Healthcare Provider Details

I. General information

NPI: 1003006503
Provider Name (Legal Business Name): OLUGBEMIGA EBENEZER JEGEDE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2007
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 E WENDOVER AVE
GREENSBORO NC
27401-1205
US

IV. Provider business mailing address

509 N ELAM AVE # 3E
GREENSBORO NC
27403-1129
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-4444
  • Fax: 336-832-4445
Mailing address:
  • Phone: 810-908-9996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2014-00579
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301090347
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: