1093732950 NPI number — DR. OLABODE OLAOSEBIKAN DESALU MD

Table of content: DIMITRIOS BARMPOULETOS M.D. (NPI 1629260013)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093732950 NPI number — DR. OLABODE OLAOSEBIKAN DESALU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DESALU
Provider First Name:
OLABODE
Provider Middle Name:
OLAOSEBIKAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
OSHODI
Provider Other First Name:
OLABODE
Provider Other Middle Name:
OLAOSEBIKAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093732950
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/22/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 CHILDREN'S WAY
Provider Second Line Business Mailing Address:
SLOT 844
Provider Business Mailing Address City Name:
LITTLE ROCK
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72202-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-364-2090
Provider Business Mailing Address Fax Number:
501-364-3929

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 S 52ND ST STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROGERS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72758-8640
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-254-1100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/16/2006

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: 208000000X , with the licence number:  15345R , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: E-11228 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X , with the licence number: T2018-031 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 200069660 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1470635 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 200775600A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 176387001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".




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