Healthcare Provider Details

I. General information

NPI: 1962713461
Provider Name (Legal Business Name): ADEDOYIN OKUSANYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2010
Last Update Date: 02/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6613 49TH ST N
PINELLAS PARK FL
33781-5728
US

IV. Provider business mailing address

8116 RIVERMONT WAY
TEMPLE TERRACE FL
33637
US

V. Phone/Fax

Practice location:
  • Phone: 727-527-6611
  • Fax:
Mailing address:
  • Phone: 813-482-5734
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME129198
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: