Basic Information
| Provider Information | |||||||||
| NPI: | 1710058730 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OGUNRO | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 145 HOSPITAL AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143752070 | ||||||||
| FaxNumber: | 8143752076 | ||||||||
| Practice Location | |||||||||
| Address1: | 145 HOSPITAL AVE | ||||||||
| Address2: | SUITE 211 | ||||||||
| City: | DU BOIS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 158011462 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8143752070 | ||||||||
| FaxNumber: | 8143752076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0600X | 95-118 | NM | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | 49598 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | MD036291L | PA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0600X | TP318 | KY | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology |
ID Information
| ID | Type | State | Issuer | Description | 00237590 | 05 | NY | MEDICAID | 7100413180 | 05 | KY | MEDICAID | 0010358330005 | 05 | PA | MEDICAID |