Healthcare Provider Details

I. General information

NPI: 1457627630
Provider Name (Legal Business Name): OLUWATOSIN ADEMOLA OGUNJEMILUSI MD-MAY 10, 2012
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TOSIN ADEMOLA JEMILUSI MD

II. Dates (important events)

Enumeration Date: 04/01/2012
Last Update Date: 04/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 E 98TH ST APT 4I-1
NEW YORK NY
10029-6552
US

IV. Provider business mailing address

50 E 98TH ST APT 4I-1
NEW YORK NY
10029-6552
US

V. Phone/Fax

Practice location:
  • Phone: 646-301-5738
  • Fax:
Mailing address:
  • Phone: 646-301-5738
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2032026
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: