Healthcare Provider Details

I. General information

NPI: 1720025513
Provider Name (Legal Business Name): OLABODE OLUMOFIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 10/22/2025
Certification Date: 10/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 W 40TH AVE SUITE 1C
PINE BLUFF AR
71603-6940
US

IV. Provider business mailing address

1801 W 40TH AVE STE 1C
PINE BLUFF AR
71603-6956
US

V. Phone/Fax

Practice location:
  • Phone: 870-535-4141
  • Fax: 870-535-9180
Mailing address:
  • Phone: 870-535-4141
  • Fax: 870-535-4141

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberE3124
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-3124
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: