Healthcare Provider Details

I. General information

NPI: 1790816700
Provider Name (Legal Business Name): SEKI A. BALOGUN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 12/17/2021
Certification Date: 12/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 NE 10TH ST STE 4F
OKLAHOMA CITY OK
73104-5417
US

IV. Provider business mailing address

920 STANTON L YOUNG BLVD STE 2410
OKLAHOMA CITY OK
73104-5036
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-8558
  • Fax: 405-271-3887
Mailing address:
  • Phone: 405-271-8558
  • Fax: 405-271-3887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number38433
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number0101231678
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: