MEDICARE: IMMANUEL OMOGORIOLA OLARINDE 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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1619766052
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMMANUEL OMOGORIOLA OLARINDE M.D.

Provider Business Mailing Address
First Line	:	CREIGHTON UNIVERSITY
Second Line	:	3100 N. CENTRAL AVENUE
City	:	PHOENIX
State	:	AZ
Zip	:	85012
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	VALLEYWISE HEALTH
Second Line	:	2601 E ROOSEVELT ST
City	:	PHOENIX
State	:	AZ
Zip	:	85008
Country	:	US
Telephone Number	:	602-344-5011
Fax Number	:

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

Provider Enumeration Date	:	05/02/2025
Last Update Date	:	01/21/2026

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