Healthcare Provider Details

I. General information

NPI: 1902609589
Provider Name (Legal Business Name): JONATHAN-KOLADE ODUFALU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JONATHAN ODUFALU MD

II. Dates (important events)

Enumeration Date: 03/31/2025
Last Update Date: 03/31/2025
Certification Date: 03/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 UNIVERSITY AVE BLDG II
RIVERSIDE CA
92521-9800
US

IV. Provider business mailing address

900 UNIVERSITY AVE BLDG II
RIVERSIDE CA
92521-9800
US

V. Phone/Fax

Practice location:
  • Phone: 951-827-4618
  • Fax: 951-263-7238
Mailing address:
  • Phone: 951-827-4618
  • Fax: 951-263-7238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: