Provider Demographics
NPI:1649692930
Name:OLUWAFEMI ODEYALE PODIATRY PC
Entity type:Organization
Organization Name:OLUWAFEMI ODEYALE PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUWAFEMI
Authorized Official - Middle Name:S
Authorized Official - Last Name:ODEYALE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-954-1744
Mailing Address - Street 1:82 SAINT MARKS PL
Mailing Address - Street 2:APT 1I
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1644
Mailing Address - Country:US
Mailing Address - Phone:718-954-1744
Mailing Address - Fax:
Practice Address - Street 1:82 SAINT MARKS PL
Practice Address - Street 2:APT 1I
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-1644
Practice Address - Country:US
Practice Address - Phone:718-954-1744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-06
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006528213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty