Provider Demographics
NPI:1730968876
Name:OLUYEMI, OLUMUYIWA OLUDARE
Entity type:Individual
Prefix:
First Name:OLUMUYIWA
Middle Name:OLUDARE
Last Name:OLUYEMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:648 S 19TH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07103-1179
Mailing Address - Country:US
Mailing Address - Phone:717-727-6647
Mailing Address - Fax:
Practice Address - Street 1:648 S 19TH ST APT 2
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-1179
Practice Address - Country:US
Practice Address - Phone:717-727-6647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ056736047609871172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver