Healthcare Provider Details

I. General information

NPI: 1104454040
Provider Name (Legal Business Name): DANIEL OLUWADARE ESAN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2020
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4953 VAN DYKE RD
LUTZ FL
33558-4813
US

IV. Provider business mailing address

1102 BRIGADOON DR
CLEARWATER FL
33759-2931
US

V. Phone/Fax

Practice location:
  • Phone: 813-544-8719
  • Fax:
Mailing address:
  • Phone: 443-985-7214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS18082
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: