Healthcare Provider Details

I. General information

NPI: 1467728113
Provider Name (Legal Business Name): MOSES F OLORUNNISOLA JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 11/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 ROUTE 72 W
MANAHAWKIN NJ
08050-2412
US

IV. Provider business mailing address

1140 ROUTE 72 W
MANAHAWKIN NJ
08050-2412
US

V. Phone/Fax

Practice location:
  • Phone: 609-597-6405
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA09681500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: