Healthcare Provider Details

I. General information

NPI: 1609339985
Provider Name (Legal Business Name): KIANDRA SADE OLUFOWOBI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2019
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PL # 1136
NEW YORK NY
10029-6504
US

IV. Provider business mailing address

324 E 81ST ST APT 5FW
NEW YORK NY
10028-3930
US

V. Phone/Fax

Practice location:
  • Phone: 203-610-9381
  • Fax:
Mailing address:
  • Phone: 203-610-9381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number026130
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: