Provider Demographics
NPI:1548289770
Name:OGUNTOLU, YEMI
Entity type:Individual
Prefix:
First Name:YEMI
Middle Name:
Last Name:OGUNTOLU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17638 SHERMAN WAY
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91406-3509
Mailing Address - Country:US
Mailing Address - Phone:818-881-1136
Mailing Address - Fax:818-881-5839
Practice Address - Street 1:17638 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3509
Practice Address - Country:US
Practice Address - Phone:818-881-1136
Practice Address - Fax:818-881-5839
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4555100001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4555100001Medicare ID - Type UnspecifiedPROVIDER #