Healthcare Provider Details

I. General information

NPI: 1336579812
Provider Name (Legal Business Name): RAPHAEL OLUSOLA OGUNREMI MHR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 01/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 UNITED FOUNDERS BLVD STE 128
OKLAHOMA CITY OK
73112-3958
US

IV. Provider business mailing address

3000 UNITED FOUNDERS BLVD STE #128
OKLAHOMA CITY OK
73112-3958
US

V. Phone/Fax

Practice location:
  • Phone: 405-607-4922
  • Fax:
Mailing address:
  • Phone: 405-607-4922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number301386
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: