Healthcare Provider Details

I. General information

NPI: 1588175939
Provider Name (Legal Business Name): AYODEJI OGUNDARE LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9230 OLD NEWTOWN RD
PHILADELPHIA PA
19115-4908
US

IV. Provider business mailing address

9230 OLD NEWTOWN RD
PHILADELPHIA PA
19115-4908
US

V. Phone/Fax

Practice location:
  • Phone: 267-475-2834
  • Fax:
Mailing address:
  • Phone: 267-475-2834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number303623
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: