Provider Demographics
NPI:1215997820
Name:BALOGUN, OLAJIDE A (MD)
Entity type:Individual
Prefix:DR
First Name:OLAJIDE
Middle Name:A
Last Name:BALOGUN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1165 HIGHWAY 1 S
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LUGOFF
Mailing Address - State:SC
Mailing Address - Zip Code:29078-8966
Mailing Address - Country:US
Mailing Address - Phone:803-408-0225
Mailing Address - Fax:803-408-0729
Practice Address - Street 1:1165 HIGHWAY 1 S
Practice Address - Street 2:SUITE 200
Practice Address - City:LUGOFF
Practice Address - State:SC
Practice Address - Zip Code:29078-8966
Practice Address - Country:US
Practice Address - Phone:803-408-0225
Practice Address - Fax:803-408-0729
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC20381208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC203817Medicaid