Healthcare Provider Details

I. General information

NPI: 1740514371
Provider Name (Legal Business Name): MR. OLUBUNMI OLANIPEKUN OGUNWALE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: OLUBUNMI OLANIPEKUN OGUNWALE RN

II. Dates (important events)

Enumeration Date: 09/30/2009
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 EAST DR APT 2E
BRENTWOOD NY
11717-1139
US

IV. Provider business mailing address

12 EAST DR APT 2E
BRENTWOOD NY
11717-1139
US

V. Phone/Fax

Practice location:
  • Phone: 631-357-3911
  • Fax:
Mailing address:
  • Phone: 631-357-3911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number611147-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: