Healthcare Provider Details

I. General information

NPI: 1356145072
Provider Name (Legal Business Name): OLUWASEUN OGUNSUYI OGUNTOMOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2025
Last Update Date: 04/02/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 N EAST AVE
JACKSON MI
49201-1753
US

IV. Provider business mailing address

1630 WELLS BRANCH PKWY APT 1335
AUSTIN TX
78728-7173
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-3998
  • Fax: 517-205-7050
Mailing address:
  • Phone: 504-875-7010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4351054019
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: