Provider Demographics
NPI:1427274042
Name:OLUBANJO, OLUGBEMINIYI I (MD)
Entity type:Individual
Prefix:
First Name:OLUGBEMINIYI
Middle Name:I
Last Name:OLUBANJO
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:PO BOX 360541
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15251-6541
Mailing Address - Country:US
Mailing Address - Phone:972-525-9900
Mailing Address - Fax:469-333-7988
Practice Address - Street 1:2901 E BROAD ST
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-9147
Practice Address - Country:US
Practice Address - Phone:972-525-9900
Practice Address - Fax:469-333-7988
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11012909A208D00000X
TXN1033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8BQ006OtherBCBS
TX195929801Medicaid
TXP00703560OtherRAILROAD MEDICARE
IN11012909AOtherRESIDENCY PERMIT
IN11012909AOtherRESIDENCY PERMIT
TX195929801Medicaid
IN169380F4Medicare PIN
IN236040H2Medicare PIN