Healthcare Provider Details

I. General information

NPI: 1023981628
Provider Name (Legal Business Name): OLUBUNMI ABIGAIL OLOJEDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2025
Last Update Date: 09/29/2025
Certification Date: 09/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 GRANT AVE
LAKE KATRINE NY
12449-5340
US

IV. Provider business mailing address

3438 BELL BLVD STE 301
BAYSIDE NY
11361-1739
US

V. Phone/Fax

Practice location:
  • Phone: 845-336-3500
  • Fax:
Mailing address:
  • Phone: 718-709-0940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberP138616
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: