Healthcare Provider Details

I. General information

NPI: 1316486897
Provider Name (Legal Business Name): OLUWATOBI OGUN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 08/09/2022
Certification Date: 08/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4400 EMILE ST
OMAHA NE
68198-3285
US

IV. Provider business mailing address

988102 NEBRASKA MEDICAL CTR
OMAHA NE
68198-8102
US

V. Phone/Fax

Practice location:
  • Phone: 402-559-8390
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204F00000X
TaxonomyTransplant Surgery Physician
License Number7874
License Number StateNE
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34493
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: