Provider Demographics
NPI:1285958884
Name:OLAGUNJU, OLUMIDE T (MD)
Entity type:Individual
Prefix:DR
First Name:OLUMIDE
Middle Name:T
Last Name:OLAGUNJU
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:PO BOX 81452
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89180-1452
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-3799
Practice Address - Street 1:1107 US HIGHWAY 395 N
Practice Address - Street 2:
Practice Address - City:GARDNERVILLE
Practice Address - State:NV
Practice Address - Zip Code:89410
Practice Address - Country:US
Practice Address - Phone:775-782-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-25
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV14674208M00000X, 207R00000X
UT13284776-1205208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD60329818OtherWA LIC