Healthcare Provider Details

I. General information

NPI: 1548423114
Provider Name (Legal Business Name): OLUROTIMI BADERO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2008
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5240 ROBINSON RD
JACKSON MS
39204-4134
US

IV. Provider business mailing address

5240 ROBINSON RD
JACKSON MS
39204-4134
US

V. Phone/Fax

Practice location:
  • Phone: 601-398-0904
  • Fax: 601-398-2149
Mailing address:
  • Phone: 601-398-0904
  • Fax: 601-398-2149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number21527
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number21527
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: