Healthcare Provider Details

I. General information

NPI: 1427275049
Provider Name (Legal Business Name): ADETOKUNBO OLUKOREDE OMORUYI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ADETOKUNBO OLUKOREDE DAWODU M.D.

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 09/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S FLOYD ST STE 403
LOUISVILLE KY
40202-1837
US

IV. Provider business mailing address

PO BOX 909
LOUISVILLE KY
40201-0909
US

V. Phone/Fax

Practice location:
  • Phone: 502-588-3400
  • Fax: 502-588-3401
Mailing address:
  • Phone: 502-588-3400
  • Fax: 502-588-3401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number42024
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number35.086930
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number42024
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: