1770683732 NPI number — ABIMBOLA A ODUKOYA M.D.

Table of content: ABIMBOLA A ODUKOYA M.D. (NPI 1770683732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770683732 NPI number — ABIMBOLA A ODUKOYA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ODUKOYA
Provider First Name:
ABIMBOLA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

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:
1770683732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3741 ROME DR
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LAFAYETTE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
47905-4490
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
765-607-6160
Provider Business Mailing Address Fax Number:
765-607-6161

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3741 ROME DR
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LAFAYETTE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
47905-4490
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
765-607-6160
Provider Business Practice Location Address Fax Number:
765-607-6161
Provider Enumeration Date:
09/22/2006

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:  61002723 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 01062400A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01062400A . This is a "IN STATE LICENSE" identifier , issued by the state of ( IN ) . This identifiers is of the category "OTHER".
  • Identifier: 61002723 . This is a "LICENSE" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 200908770 , issued by the state of ( IN ) . This identifiers is of the category "MEDICAID".




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