Healthcare Provider Details

I. General information

NPI: 1558089342
Provider Name (Legal Business Name): OLUWOLE OLUYINKA OLUYEMI KONIGBAGBE MBBS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2022
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 E 210TH ST
BRONX NY
10467-2490
US

IV. Provider business mailing address

1 NEWBURY CT
NORTH HAVEN CT
06473-3287
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-5731
  • Fax:
Mailing address:
  • Phone: 860-265-9619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberP115301
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: