Healthcare Provider Details

I. General information

NPI: 1871682559
Provider Name (Legal Business Name): OMOBOLA ODUNTAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 10/28/2020
Certification Date: 10/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-1436
US

IV. Provider business mailing address

PO BOX 100237
GAINESVILLE FL
32610-0237
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-5159
  • Fax:
Mailing address:
  • Phone: 352-273-5159
  • Fax: 352-273-5213

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number23921
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0101241296
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME133149
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: