Healthcare Provider Details

I. General information

NPI: 1932802709
Provider Name (Legal Business Name): KASOPEFOLUWA Y. OGUNTUYO MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2023
Last Update Date: 03/22/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1468 MADISON AVE
NEW YORK NY
10029-6508
US

IV. Provider business mailing address

ONE GUSTAVE L. LEVY PLACE BOX 1076
NEW YORK NY
10029-0311
US

V. Phone/Fax

Practice location:
  • Phone: --
  • Fax:
Mailing address:
  • Phone: 212-241-3332
  • Fax: 212-426-7748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
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: