Healthcare Provider Details

I. General information

NPI: 1396961967
Provider Name (Legal Business Name): OSAWARU JUDE OMORUYI M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 BUECHEL AVE STE 105
LOUISVILLE KY
40218-2672
US

IV. Provider business mailing address

2202 BUECHEL AVE STE 105
LOUISVILLE KY
40218-2672
US

V. Phone/Fax

Practice location:
  • Phone: 502-367-3360
  • Fax: 502-367-3365
Mailing address:
  • Phone: 502-456-0494
  • Fax: 502-456-0496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.088666
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number01066757A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number42023
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: