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General NPI Number Information
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NPI Number | 1548526494
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Entity Type | Individual
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Provider Name | OMOLADE OGUN MD
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Gender | Female
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Dates
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Enumeration Date | 04/04/2012
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Last Update Date | 10/01/2021
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Provider Practice Location Address
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Address Line | 4676 ADMIRALTY WAY FL 4
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City | MARINA DEL REY
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State | CA
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Zip | 90292-6601
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Country | US
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Telephone | 310-306-6966
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 20471
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City | BAKERSFIELD
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State | CA
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Zip | 93390-0471
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Country | US
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Telephone | 310-465-8448
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | A121040
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License Number State | CA
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