Healthcare Provider Details

I. General information

NPI: 1174885834
Provider Name (Legal Business Name): OLAMIDE ODUBOGUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S BEDFORD RD
MOUNT KISCO NY
10549-3446
US

IV. Provider business mailing address

PO BOX 300
LEBANON PA
17042-0300
US

V. Phone/Fax

Practice location:
  • Phone: 914-241-1050
  • Fax:
Mailing address:
  • Phone: 717-270-7780
  • Fax: 717-274-9746

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number297359
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: