Healthcare Provider Details

I. General information

NPI: 1871858092
Provider Name (Legal Business Name): OLABODE C. OGUNWOLE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

45 NE LOOP 410 STE 900
SAN ANTONIO TX
78216-5831
US

V. Phone/Fax

Practice location:
  • Phone: 210-567-4506
  • Fax:
Mailing address:
  • Phone: 210-375-7790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberD90619
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberP9672
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: