Healthcare Provider Details

I. General information

NPI: 1104529809
Provider Name (Legal Business Name): OLADIMEJI OKUBADEJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2023
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 MAIN ST
PATERSON NJ
07503-2691
US

IV. Provider business mailing address

10201 66TH RD
FOREST HILLS NY
11375-2029
US

V. Phone/Fax

Practice location:
  • Phone: 973-754-2000
  • Fax:
Mailing address:
  • Phone: 718-830-4352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25MA13136700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: