Healthcare Provider Details

I. General information

NPI: 1336761469
Provider Name (Legal Business Name): BABATUNDE OGUNJULUGBE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2020
Last Update Date: 05/12/2020
Certification Date: 05/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 GAWAIN DR
NEWPORT NEWS VA
23602-7108
US

IV. Provider business mailing address

115 GAWAIN DR
NEWPORT NEWS VA
23602-7108
US

V. Phone/Fax

Practice location:
  • Phone: 571-234-2532
  • Fax:
Mailing address:
  • Phone: 571-234-2532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001279013
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: