Healthcare Provider Details

I. General information

NPI: 1790282713
Provider Name (Legal Business Name): OLUWASEUN BASIT OGUNBONA MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

IV. Provider business mailing address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4402
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-4000
  • Fax:
Mailing address:
  • Phone: 210-358-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZN0500X
TaxonomyNeuropathology Physician
License NumberT1797
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberT1797
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: