Healthcare Provider Details

I. General information

NPI: 1609952043
Provider Name (Legal Business Name): OPTIMUM FAMILY MEDICINE P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 NEREID AVE
BRONX NY
10470-1514
US

IV. Provider business mailing address

675 NEREID AVE
BRONX NY
10470-1514
US

V. Phone/Fax

Practice location:
  • Phone: 347-202-9545
  • Fax: 347-202-9580
Mailing address:
  • Phone: 347-202-9545
  • Fax: 347-202-9580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number236764
License Number StateNY

VIII. Authorized Official

Name: DR. OLUFUNMILAYO O ADEYANJU
Title or Position: MEDICAL DIRECTOR
Credential: M.D
Phone: 347-202-9545