Provider Demographics
NPI:1073330379
Name:STATE OF DELAWARE DEPARTMENT OF PUBLIC HEATH ACCESS PROGRAM TELEHEALTH
Entity type:Organization
Organization Name:STATE OF DELAWARE DEPARTMENT OF PUBLIC HEATH ACCESS PROGRAM TELEHEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF PHYSICIAN DIVISION OF PUBLIC
Authorized Official - Prefix:
Authorized Official - First Name:OLUBUSOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:OGUNLADE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:302-730-2941
Mailing Address - Street 1:417 FEDERAL STREET
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901
Mailing Address - Country:US
Mailing Address - Phone:302-744-4700
Mailing Address - Fax:302-744-5361
Practice Address - Street 1:417 FEDERAL STREET
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901
Practice Address - Country:US
Practice Address - Phone:302-744-4700
Practice Address - Fax:302-744-5361
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DE DPH CARE ACCESS TELEHEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1013089895Medicaid