Healthcare Provider Details

I. General information

NPI: 1184735698
Provider Name (Legal Business Name): OLUFEMI O SOYODE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 02/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6028
US

IV. Provider business mailing address

422 PLYMOUTH AVE NE
GRAND RAPIDS MI
49505-6028
US

V. Phone/Fax

Practice location:
  • Phone: 616-294-0010
  • Fax: 616-828-1802
Mailing address:
  • Phone: 616-294-0010
  • Fax: 616-828-1802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number4301081420
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: