Healthcare Provider Details

I. General information

NPI: 1972050474
Provider Name (Legal Business Name): OYEFUNKE ABIDEMI OGUNBANWO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3020 NW 181ST ST
EDMOND OK
73012-6824
US

IV. Provider business mailing address

13605 KESWICK LN
YUKON OK
73099-4030
US

V. Phone/Fax

Practice location:
  • Phone: 405-250-5706
  • Fax:
Mailing address:
  • Phone: 405-694-1313
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License NumberL0064819
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: