Healthcare Provider Details

I. General information

NPI: 1215959713
Provider Name (Legal Business Name): OLUWATOPE A MABOGUNJE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 W 3RD ST 112
DAYTON OH
45428-9000
US

IV. Provider business mailing address

4100 W 3RD ST 112
DAYTON OH
45428-9000
US

V. Phone/Fax

Practice location:
  • Phone: 937-262-2150
  • Fax: 937-267-3998
Mailing address:
  • Phone: 937-262-2150
  • Fax: 937-267-3998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG041193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: