Healthcare Provider Details

I. General information

NPI: 1770683732
Provider Name (Legal Business Name): ABIMBOLA A ODUKOYA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3741 ROME DR SUITE B
LAFAYETTE IN
47905-4490
US

IV. Provider business mailing address

3741 ROME DR SUITE B
LAFAYETTE IN
47905-4490
US

V. Phone/Fax

Practice location:
  • Phone: 765-607-6160
  • Fax: 765-607-6161
Mailing address:
  • Phone: 765-607-6160
  • Fax: 765-607-6161

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61002723
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01062400A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: