MEDICARE: DR. ABIMBOLA OLAMIDE IYANOYE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	25MA08606400	NJ
2	208000000X	Pediatrics Physician	036.121783	IL

General Provider Information

NPI Number	:	1093961732
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ABIMBOLA OLAMIDE IYANOYE M.D.

Provider Business Mailing Address
First Line	:	1702 VAN WICKLE DR
Second Line	:
City	:	FRANKLIN PARK
State	:	NJ
Zip	:	08823-2609
Country	:	US
Telephone Number	:	507-254-2070
Fax Number	:

Provider Business Practice Location Address
First Line	:	1702 VAN WICKLE DR
Second Line	:
City	:	FRANKLIN PARK
State	:	NJ
Zip	:	08823-2609
Country	:	US
Telephone Number	:	507-254-2070
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2008
Last Update Date	:	07/21/2009

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