1346244324 NPI number — OLUSOLA OLANREWAJU OGUNTOLU MD

Table of content: OLUSOLA OLANREWAJU OGUNTOLU MD (NPI 1346244324)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346244324 NPI number — OLUSOLA OLANREWAJU OGUNTOLU MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OGUNTOLU
Provider First Name:
OLUSOLA
Provider Middle Name:
OLANREWAJU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1346244324
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/29/2006
NPI Reactivation Date:
03/31/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5543 EDMONDSON PIKE
Provider Second Line Business Mailing Address:
# 44
Provider Business Mailing Address City Name:
NASHVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37211-5808
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-321-7255
Provider Business Mailing Address Fax Number:
615-321-7259

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 FELICIA ST
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
NASHVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37209-4042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-321-7255
Provider Business Practice Location Address Fax Number:
615-321-7259
Provider Enumeration Date:
06/08/2005

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: 207RP1001X , with the licence number:  MD36290 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4043600 . This is a "BC/BS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 5347585 . This is a "AETNA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 3381539 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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