Provider Demographics
NPI:1144478736
Name:OGBULU, SHAMUSIDEEN OLAYIBO (MD)
Entity type:Individual
Prefix:
First Name:SHAMUSIDEEN
Middle Name:OLAYIBO
Last Name:OGBULU
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 601992
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1992
Mailing Address - Country:US
Mailing Address - Phone:910-642-1776
Mailing Address - Fax:
Practice Address - Street 1:500 JEFFERSON STREET
Practice Address - Street 2:
Practice Address - City:WHITEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28472-3634
Practice Address - Country:US
Practice Address - Phone:910-642-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-08
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065806A207R00000X, 208M00000X
NC2011-01350207R00000X, 208M00000X
VA0101258916208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000584350OtherANTHEM PIN
IN200913430Medicaid
SCNC1486Medicaid
INP00657204OtherRR MEDICARE PIN
NC5918627Medicaid
IN227950D5Medicare PIN
IN000000584350OtherANTHEM PIN