Healthcare Provider Details

I. General information

NPI: 1528976461
Provider Name (Legal Business Name): VICTOR BUNMI OYEWOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MARK LN UNIT N2
WATERBURY CT
06704-2461
US

IV. Provider business mailing address

100 MARK LN UNIT N2
WATERBURY CT
06704-2461
US

V. Phone/Fax

Practice location:
  • Phone: 203-592-3537
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number18162
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: