1063500015 NPI number — DR. AMOS OLABISI DARE M.D.

Table of content: DR. AMOS OLABISI DARE M.D. (NPI 1063500015)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063500015 NPI number — DR. AMOS OLABISI DARE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DARE
Provider First Name:
AMOS
Provider Middle Name:
OLABISI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NONE
Provider Other First Name:
NONE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1063500015
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8185 VIA ANCHO RD
Provider Second Line Business Mailing Address:
UNIT 880347
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-844-0120
Provider Business Mailing Address Fax Number:
904-743-9225

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
544 CESERY BLVD
Provider Second Line Business Practice Location Address:
SUITE 310
Provider Business Practice Location Address City Name:
JACKSONVILLE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-743-9222
Provider Business Practice Location Address Fax Number:
904-743-9225
Provider Enumeration Date:
10/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X , with the licence number:  ME91254 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 271212100 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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