Basic Information
| Provider Information | |||||||||
| NPI: | 1003006503 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JEGEDE | ||||||||
| FirstName: | OLUGBEMIGA | ||||||||
| MiddleName: | EBENEZER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 509 N ELAM AVE # 3E | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274031129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8109089996 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 201 E WENDOVER AVE | ||||||||
| Address2: | |||||||||
| City: | GREENSBORO | ||||||||
| State: | NC | ||||||||
| PostalCode: | 274011205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368324444 | ||||||||
| FaxNumber: | 3368324445 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2007 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 2014-00579 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301090347 | MI | N | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.