Provider Demographics
NPI:1124098553
Name:OGLESBY, ALLAN C (MD)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:C
Last Name:OGLESBY
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 1:61 MEMORIAL MEDICAL PKWY
Mailing Address - Street 2:SUITE 3805
Mailing Address - City:PALM COAST
Mailing Address - State:FL
Mailing Address - Zip Code:32164-5981
Mailing Address - Country:US
Mailing Address - Phone:386-586-1740
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 3804
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5982
Practice Address - Country:US
Practice Address - Phone:386-586-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0060915207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375990300Medicaid