Healthcare Provider Details

I. General information

NPI: 1124096383
Provider Name (Legal Business Name): OLABODE O OGIDAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/25/2025
Certification Date: 03/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1138 E CHESTNUT AVE
VINELAND NJ
08360-5053
US

IV. Provider business mailing address

1138 E CHESTNUT AVE
VINELAND NJ
08360-5053
US

V. Phone/Fax

Practice location:
  • Phone: 856-692-1108
  • Fax: 856-692-2077
Mailing address:
  • Phone: 856-692-1108
  • Fax: 856-692-2077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA06442400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: