Healthcare Provider Details

I. General information

NPI: 1639765571
Provider Name (Legal Business Name): MR. OLUSEGUN OLOWOLABI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17756 MEADOW DR
JAMAICA NY
11434-4944
US

IV. Provider business mailing address

17756 MEADOW DR
JAMAICA NY
11434-4944
US

V. Phone/Fax

Practice location:
  • Phone: 718-736-4338
  • Fax:
Mailing address:
  • Phone: 718-736-4338
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number307134-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: