Healthcare Provider Details

I. General information

NPI: 1679052450
Provider Name (Legal Business Name): DR. OLALEKAN IFEOLUWA OLAOLU
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: OLALEKAN IFEOLUWA OLAIFA

II. Dates (important events)

Enumeration Date: 08/12/2018
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 O'BRIEN DRIVE
MIDDLETOWN CT
06457
US

IV. Provider business mailing address

70 O'BRIEN DRIVE
MIDDLETOWN CT
06457-1805
US

V. Phone/Fax

Practice location:
  • Phone: 860-262-5428
  • Fax:
Mailing address:
  • Phone: 404-399-9616
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number71769
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084F0202X
TaxonomyForensic Psychiatry Physician
License Number71769
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: