Provider Demographics
NPI:1902907223
Name:OLUTADE, INI-ABASI JOYCE (MD)
Entity Type:Individual
Prefix:
First Name:INI-ABASI
Middle Name:JOYCE
Last Name:OLUTADE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BUSINESS PARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-6015
Mailing Address - Country:US
Mailing Address - Phone:601-991-3040
Mailing Address - Fax:601-991-3399
Practice Address - Street 1:100 BUSINESS PARK DR STE A
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-6015
Practice Address - Country:US
Practice Address - Phone:601-991-3040
Practice Address - Fax:601-991-3399
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16022207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119586Medicaid
MS080123844Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MSG64498Medicare UPIN
MS388703YS8TMedicare PIN
MS080002809Medicare ID - Type Unspecified