Healthcare Provider Details

I. General information

NPI: 1609804350
Provider Name (Legal Business Name): OLUKEMI A WALLACE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 08/14/2024
Certification Date: 08/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 W MANCHESTER BLVD
INGLEWOOD CA
90305-2514
US

IV. Provider business mailing address

15342 HAWTHORNE BLVD SUITE 102
LAWNDALE CA
90260-2152
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-8400
  • Fax: 310-644-8424
Mailing address:
  • Phone: 310-644-8400
  • Fax: 310-644-8424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA48240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: