Healthcare Provider Details

I. General information

NPI: 1316292121
Provider Name (Legal Business Name): OLAIDE OMOWONUOLA ABIODUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2012
Last Update Date: 09/27/2026
Certification Date: 09/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 E VALLEY AUTO DR STE 210
MESA AZ
85206-4609
US

IV. Provider business mailing address

1641 E OSBORN RD STE 4
PHOENIX AZ
85016-7146
US

V. Phone/Fax

Practice location:
  • Phone: 480-630-2886
  • Fax: 480-378-8124
Mailing address:
  • Phone: 480-630-2886
  • Fax: 480-378-8124

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number50099
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number50099
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number50099
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: