MEDICARE: DR. OSAWARU JUDE OMORUYI 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	207Q00000X	Family Medicine Physician	42023	KY
2	207Q00000X	Family Medicine Physician	35.088666	OH
3	207QG0300X	Geriatric Medicine (Family Medicine) Physician	01066757A	IN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1396961967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OSAWARU JUDE OMORUYI M.D

Provider Business Mailing Address
First Line	:	2202 BUECHEL AVE
Second Line	:	STE 105
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-2672
Country	:	US
Telephone Number	:	502-456-0494
Fax Number	:	502-456-0496

Provider Business Practice Location Address
First Line	:	2202 BUECHEL AVE STE 103
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40218-2672
Country	:	US
Telephone Number	:	502-456-0494
Fax Number	:	502-456-0496

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

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	04/14/2026

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