1306046214 NPI number — OLUTAYO T OLABIGE M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306046214 NPI number — OLUTAYO T OLABIGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLABIGE
Provider First Name:
OLUTAYO
Provider Middle Name:
T
Provider Name Prefix Text:
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:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306046214
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/31/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 141032
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GAINESVILLE
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32614-1032
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
646-623-8106
Provider Business Mailing Address Fax Number:
352-581-6226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1548B S WATER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STARKE
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32091-4511
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-346-3127
Provider Business Practice Location Address Fax Number:
352-581-6226
Provider Enumeration Date:
07/19/2007

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: 207RN0300X , with the licence number:  ME119764 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RN0300X , with the licence number: 01068818A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 48779 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100389860 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 019517200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 201272180 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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