Healthcare Provider Details

I. General information

NPI: 1871162156
Provider Name (Legal Business Name): ADEDOYIN OKULATE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 12/20/2024
Certification Date: 12/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 OLD LEBANON RD
CAMPBELLSVILLE KY
42718-9615
US

IV. Provider business mailing address

1698 OLD LEBANON RD
CAMPBELLSVILLE KY
42718-3319
US

V. Phone/Fax

Practice location:
  • Phone: 270-465-3561
  • Fax:
Mailing address:
  • Phone: 270-465-3561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number60142
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60142
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: