Healthcare Provider Details

I. General information

NPI: 1144235557
Provider Name (Legal Business Name): OMIYOSOYE OLOLADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2006
Last Update Date: 10/13/2023
Certification Date: 10/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 US HIGHWAY 41 STE I
SCHERERVILLE IN
46375-1278
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-864-3950
  • Fax: 219-864-3952
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036120689
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: