MEDICARE: MR. LAWRENCE OLU JEGEDE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	347C00000X	Private Vehicle

General Provider Information

NPI Number	:	1194207571
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. LAWRENCE OLU JEGEDE

Provider Business Mailing Address
First Line	:	1525 RUSH ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-1543
Country	:	US
Telephone Number	:	757-729-8587
Fax Number	:	757-524-5579

Provider Business Practice Location Address
First Line	:	1525 RUSH ST
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23502-1543
Country	:	US
Telephone Number	:	757-729-8587
Fax Number	:	757-524-5579

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/03/2018
Last Update Date	:	09/03/2018

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