Healthcare Provider Details

I. General information

NPI: 1144572744
Provider Name (Legal Business Name): OLUGBENGA OBAWEYA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2012
Last Update Date: 10/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 E 92 STREET 6R
BROOKLYN NY
11212-1205
US

IV. Provider business mailing address

333 E 92 STREET 6R
BROOKLYN NY
11212-1205
US

V. Phone/Fax

Practice location:
  • Phone: 347-709-1285
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: