Individual
THEOPHILUS TOLULOPE OGUNGBAMIGBE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1302 BANKSTON LN, MANSFIELD, TX 76063-8676
(785) 354-9591
Mailing address
1302 BANKSTON LN, MANSFIELD, TX 76063-8676
(917) 517-4069
Taxonomy
Speciality
Code
Description
License number
State
207RC0200X
Critical Care Medicine (Internal Medicine) Physician
04-32614
KS
207RP1001X
Pulmonary Disease Physician
04-32614
KS
207RP1001X
Pulmonary Disease Physician
Primary
Q0140
TX
207RS0012X
Sleep Medicine (Internal Medicine) Physician
04-32614
KS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
106587
MEDICARE PTAN
KS
05
—
200438400A
—
KS
01
—
230637
LICENSE
NY
01
—
P00426465
RAILROAD MEDICARE
KS
Enumeration date
07/22/2006
Last updated
05/06/2024
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