Healthcare Provider Details
I. General information
NPI: 1588629240
Provider Name (Legal Business Name): AKINNIYI BABASOLA ODUTOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 04/18/2006
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
475 SUMNER AVE
SPRINGFIELD MA
01108-2321
US
IV. Provider business mailing address
84 LAWRENCE DR
LONGMEADOW MA
01106-1618
US
V. Phone/Fax
- Phone: 413-241-6152
- Fax: 413-241-6153
- Phone: 413-241-6152
- Fax: 413-241-6153
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 208000000X |
| Taxonomy | Pediatrics Physician |
| License Number | 210668 |
| License Number State | MA |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 32424 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | PROVIDER HNE # |
| # 2 | |
| Identifier | 97431403 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | NETWORK HEALTH |
| # 3 | |
| Identifier | 2450995 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | UNITED HEALTHCARE # |
| # 4 | |
| Identifier | 8207136 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | CIGNA |
| # 5 | |
| Identifier | MO0497950A |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | CSR NUMBER |
| # 6 | |
| Identifier | 210668 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | PROVIDER CONNECTICARE # |
| # 7 | |
| Identifier | 3842111 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | AETNA # |
| # 8 | |
| Identifier | 2159821 / 110080500A |
| Identifier Type | MEDICAID |
| Identifier State | MA |
| Identifier Issuer | |
| # 9 | |
| Identifier | 692538 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | TUFTS # |
| # 10 | |
| Identifier | 000000049829 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | BMC HEALTHNET # |
| # 11 | |
| Identifier | 0030525 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | NEIGHBORHOOD HEALTH PLAN # |
| # 12 | |
| Identifier | 49849 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | PROVIDER CHILDRENS MEDICAL SECURITY PLAN # |
| # 13 | |
| Identifier | J25872 |
| Identifier Type | OTHER |
| Identifier State | MA |
| Identifier Issuer | BC/BS NUMBER |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
