Healthcare Provider Details

I. General information

NPI: 1477561066
Provider Name (Legal Business Name): OLUTOSIN O OBASANYA-EYITAYO PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: OLUTOSIN O OBASANYA

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2465 BROADWAY
NEW YORK NY
10025-7486
US

IV. Provider business mailing address

17404 140TH AVE
JAMAICA NY
11434-4600
US

V. Phone/Fax

Practice location:
  • Phone: 212-877-2525
  • Fax:
Mailing address:
  • Phone: 718-712-0551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number026154
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: