Healthcare Provider Details

I. General information

NPI: 1093940918
Provider Name (Legal Business Name): OMODELE IBITOLA HOGAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2009
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-5301
US

IV. Provider business mailing address

5 PLAINSBORO RD STE 300
PLAINSBORO NJ
08536-1915
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6028
  • Fax: 570-271-5845
Mailing address:
  • Phone: 609-853-7272
  • Fax: 609-853-7245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number13694
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MA11280500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberME119257
License Number StateFL
# 4
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberMD465107
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: