Healthcare Provider Details

I. General information

NPI: 1710566195
Provider Name (Legal Business Name): OLUTIMILEHIN OYENIRAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2021
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3274 STEINWAY ST
ASTORIA NY
11103-4006
US

IV. Provider business mailing address

180 ASHLAND PL APT 1601
BROOKLYN NY
11217-5590
US

V. Phone/Fax

Practice location:
  • Phone: 347-354-1328
  • Fax: 332-296-8382
Mailing address:
  • Phone: 908-344-8963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number77510
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number330858
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: