Basic Information
Provider Information | |||||||||
NPI: | 1598911323 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | OGUNSOLA | ||||||||
FirstName: | OLUDARE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OGUNSOLA | ||||||||
OtherFirstName: | DARE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | D.O. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 272 HOSPITAL RD STE 6 | ||||||||
Address2: |   | ||||||||
City: | CHILLICOTHE | ||||||||
State: | OH | ||||||||
PostalCode: | 456019031 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7407794222 | ||||||||
FaxNumber: | 7407794257 | ||||||||
Practice Location | |||||||||
Address1: | 4437 STATE ROUTE 159 STE G15 | ||||||||
Address2: |   | ||||||||
City: | CHILLICOTHE | ||||||||
State: | OH | ||||||||
PostalCode: | 456017065 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7407794598 | ||||||||
FaxNumber: | 7407794599 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/12/2008 | ||||||||
LastUpdateDate: | 12/14/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/14/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | 34.012784 | OH | Y |   | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
ID | Type | State | Issuer | Description | 0218810 | 05 | OH |   | MEDICAID |