Healthcare Provider Details

I. General information

NPI: 1619088812
Provider Name (Legal Business Name): DIANE SOPHIA OJUGBELI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

304 GENESEE ST
CHITTENANGO NY
13037-0001
US

IV. Provider business mailing address

1004 GILL ST
CHITTENANGO NY
13037-0001
US

V. Phone/Fax

Practice location:
  • Phone: 315-687-6467
  • Fax: 315-687-6041
Mailing address:
  • Phone: 315-687-7319
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number219809-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: