Healthcare Provider Details

I. General information

NPI: 1093732950
Provider Name (Legal Business Name): OLABODE OLAOSEBIKAN DESALU MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLABODE OLAOSEBIKAN OSHODI MD

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 S 52ND ST STE 200
ROGERS AR
72758-8640
US

IV. Provider business mailing address

1 CHILDREN'S WAY SLOT 844
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 479-254-1100
  • Fax:
Mailing address:
  • Phone: 501-364-2090
  • Fax: 501-364-3929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number15345R
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberE-11228
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberT2018-031
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: