Healthcare Provider Details

I. General information

NPI: 1609538016
Provider Name (Legal Business Name): OLUFUNMILOLA ABIODUN OLUBUKOLA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLUFUNMILOLA ABIODUN OLUBUKOLA MD

II. Dates (important events)

Enumeration Date: 10/13/2021
Last Update Date: 04/13/2023
Certification Date: 04/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1502 VILLAGE OAK LN
KISSIMMEE FL
34746-6558
US

IV. Provider business mailing address

6900 TAVISTOCK LAKES BLVD STE 300
ORLANDO FL
32827-7592
US

V. Phone/Fax

Practice location:
  • Phone: 407-627-0066
  • Fax: 407-440-4054
Mailing address:
  • Phone: 321-332-6947
  • Fax: 497-286-4515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberTBAJLDM-15-940I
License Number StatePR
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberACN1496
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: