Provider Demographics
NPI:1104978600
Name:OLUWAGBENGA SERRANO
Entity type:Organization
Organization Name:OLUWAGBENGA SERRANO
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWAGBENGA
Authorized Official - Middle Name:
Authorized Official - Last Name:SERRANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-367-3637
Mailing Address - Street 1:PO BOX 1149
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-1149
Mailing Address - Country:US
Mailing Address - Phone:928-367-3637
Mailing Address - Fax:928-367-3638
Practice Address - Street 1:218 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-7013
Practice Address - Country:US
Practice Address - Phone:928-367-3637
Practice Address - Fax:928-367-3638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-17
Last Update Date:2012-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29877207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ025539Medicaid
AZZ108776Medicare PIN