Healthcare Provider Details

I. General information

NPI: 1053082925
Provider Name (Legal Business Name): MAXWELL OLUMIDE OKUNOLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 06/11/2023
Certification Date: 06/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

1731 E 120TH ST
LOS ANGELES CA
90059-3051
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-0425
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number11408
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: