Healthcare Provider Details

I. General information

NPI: 1093388910
Provider Name (Legal Business Name): IRIYISE OMOWUNMI OLORUNTOBA-OJU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

2801 NW 23RD BLVD APT D28
GAINESVILLE FL
32605-5912
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8234
  • Fax:
Mailing address:
  • Phone: 352-226-3118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number005001395
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: