Provider Demographics
NPI:1215960968
Name:OLU OREDUGBA,M.D. A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:OLU OREDUGBA,M.D. A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:OLU
Authorized Official - Middle Name:
Authorized Official - Last Name:OREDUGBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-671-3148
Mailing Address - Street 1:8540 S SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045
Mailing Address - Country:US
Mailing Address - Phone:310-671-3148
Mailing Address - Fax:310-671-0878
Practice Address - Street 1:575 E HARDY ST
Practice Address - Street 2:SUITE 104
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4036
Practice Address - Country:US
Practice Address - Phone:310-671-3148
Practice Address - Fax:310-671-0878
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG39345207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOG393450Medicaid
CA390007978OtherRAILROAD MEDICARE
CAG39345Medicare ID - Type Unspecified
CA390007978OtherRAILROAD MEDICARE
CAOOG393450Medicaid