Healthcare Provider Details

I. General information

NPI: 1659682854
Provider Name (Legal Business Name): BAMIDELE AYOOLA OLATUNBOSUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9740 N 56TH ST STE B
TEMPLE TERRACE FL
33617-5500
US

IV. Provider business mailing address

425 W COLONIAL DR STE 303
ORLANDO FL
32804-6863
US

V. Phone/Fax

Practice location:
  • Phone: 813-200-7717
  • Fax:
Mailing address:
  • Phone: 321-635-2190
  • Fax: 689-304-0303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberME148937
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number142113
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA143986
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: