Healthcare Provider Details

I. General information

NPI: 1891159083
Provider Name (Legal Business Name): OLUKEMI ODUYERU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2016
Last Update Date: 12/30/2024
Certification Date: 12/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 AREA MARINE CENTERED MEDICAL HOME CAMP
PENDLETON CA
92058
US

IV. Provider business mailing address

PO BOX 555911
CAMP PENDLETON CA
92055-5911
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-3784
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License NumberDR.0067018
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDR.0067018
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: