Healthcare Provider Details

I. General information

NPI: 1871895037
Provider Name (Legal Business Name): DR. OLUBIMPE AYENI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2010
Last Update Date: 11/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 BROOKLINE AVE
BOSTON MA
02215-5400
US

IV. Provider business mailing address

811-135 JAMES STREET SOUTH
HAMILTON ONTARIO
L8P 2Z6
CA

V. Phone/Fax

Practice location:
  • Phone: 617-667-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number84534
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: