Healthcare Provider Details

I. General information

NPI: 1548502867
Provider Name (Legal Business Name): BAMIDELE OLUPONA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2013
Last Update Date: 10/21/2022
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 SW 37TH AVE STE 604
MIAMI FL
33133-2750
US

IV. Provider business mailing address

2601 SW 37TH AVE STE 604
MIAMI FL
33133-2750
US

V. Phone/Fax

Practice location:
  • Phone: 305-587-4247
  • Fax: 866-834-5611
Mailing address:
  • Phone: 305-587-4247
  • Fax: 866-834-5611

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberPO3757
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberPO3757
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO3757
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: