Healthcare Provider Details

I. General information

NPI: 1053900266
Provider Name (Legal Business Name): OMOBOLANLE MOROUNKEJI ALLI-BALOGUN MD,MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1276 FULTON AVE FL 5
BRONX NY
10456-3402
US

IV. Provider business mailing address

1276 FULTON AVE FL 5
BRONX NY
10456-3402
US

V. Phone/Fax

Practice location:
  • Phone: 718-590-1800
  • Fax:
Mailing address:
  • Phone: 718-590-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number332012
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: