Provider Demographics
NPI:1124310743
Name:BALOGUN, KHADIJAT OMOLOLA (MD)
Entity type:Individual
Prefix:DR
First Name:KHADIJAT
Middle Name:OMOLOLA
Last Name:BALOGUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4145
Mailing Address - Country:US
Mailing Address - Phone:860-649-3477
Mailing Address - Fax:860-649-0011
Practice Address - Street 1:353 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4145
Practice Address - Country:US
Practice Address - Phone:860-649-3477
Practice Address - Fax:860-649-0011
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT56518207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology