Provider Demographics
NPI:1497108690
Name:ODEKUNLE, RAPHAEL OLUSEUN (MD)
Entity type:Individual
Prefix:
First Name:RAPHAEL
Middle Name:OLUSEUN
Last Name:ODEKUNLE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:181 FRANKLIN AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-2900
Mailing Address - Country:US
Mailing Address - Phone:973-320-2625
Mailing Address - Fax:973-320-2626
Practice Address - Street 1:181 FRANKLIN AVE STE 301
Practice Address - Street 2:
Practice Address - City:NUTLEY
Practice Address - State:NJ
Practice Address - Zip Code:07110-2900
Practice Address - Country:US
Practice Address - Phone:973-320-2625
Practice Address - Fax:973-320-2626
Is Sole Proprietor?:No
Enumeration Date:2016-07-22
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300854207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine