Provider Demographics
NPI:1174885834
Name:ODUBOGUN, OLAMIDE (MD)
Entity type:Individual
Prefix:
First Name:OLAMIDE
Middle Name:
Last Name:ODUBOGUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 300
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:PA
Mailing Address - Zip Code:17042-0300
Mailing Address - Country:US
Mailing Address - Phone:717-270-7780
Mailing Address - Fax:717-274-9746
Practice Address - Street 1:618 CORNWALL RD
Practice Address - Street 2:BUILDING 2
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17042-7089
Practice Address - Country:US
Practice Address - Phone:717-279-6700
Practice Address - Fax:717-279-6759
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2015-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAMD454061208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program