Healthcare Provider Details

I. General information

NPI: 1336301423
Provider Name (Legal Business Name): ONWELI ERNEST OGBOLU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2008
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3009 CORPORATE LN STE 210
SUFFOLK VA
23434-9344
US

IV. Provider business mailing address

4445 CORPORATION LN STE 100
VIRGINIA BEACH VA
23462-3666
US

V. Phone/Fax

Practice location:
  • Phone: 757-623-0005
  • Fax: 757-935-1561
Mailing address:
  • Phone: 757-623-0005
  • Fax: 757-548-1129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number318289
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101253773
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: