Basic Information
| Provider Information | |||||||||
| NPI: | 1285958884 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLAGUNJU | ||||||||
| FirstName: | OLUMIDE | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 81452 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891801452 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024533799 | ||||||||
| Practice Location | |||||||||
| Address1: | 1107 US HIGHWAY 395 N | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 89410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757821524 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2010 | ||||||||
| LastUpdateDate: | 07/24/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 14674 | NV | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | 14674 | NV | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | MD60329818 | 01 | WA | WA LIC | OTHER |