Healthcare Provider Details

I. General information

NPI: 1528529120
Provider Name (Legal Business Name): OLUPONA FOOT AND ANKLE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18469 S DIXIE HWY
CUTLER BAY FL
33157-6815
US

IV. Provider business mailing address

2601 SW 37TH AVE STE 904
MIAMI FL
33133-2751
US

V. Phone/Fax

Practice location:
  • Phone: 786-573-9400
  • Fax:
Mailing address:
  • Phone: 305-587-4247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: BAMIDELE OLUGBENGA OLUPONA
Title or Position: OWNER
Credential:
Phone: 202-321-8812