Healthcare Provider Details

I. General information

NPI: 1306129713
Provider Name (Legal Business Name): YETUNDE O BALOGUN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2011
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E MARSHALL AVE STE 5001
LONGVIEW TX
75601-5524
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 903-315-2777
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberV8935
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT200039
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: