Provider Demographics
NPI:1124084512
Name:TOGUN, KIKELOMO IDOWU (MD)
Entity type:Individual
Prefix:DR
First Name:KIKELOMO
Middle Name:IDOWU
Last Name:TOGUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KIKELOMO
Other - Middle Name:IDOWU
Other - Last Name:TOGUN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:214 W 70TH ST
Mailing Address - Street 2:#104
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71106-3700
Mailing Address - Country:US
Mailing Address - Phone:318-869-2181
Mailing Address - Fax:318-869-1730
Practice Address - Street 1:214 W 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71106-3751
Practice Address - Country:US
Practice Address - Phone:318-869-2181
Practice Address - Fax:318-869-1730
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12464R208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1535915Medicaid
LA5A001Medicare ID - Type Unspecified
LAG62979Medicare UPIN