Healthcare Provider Details

I. General information

NPI: 1467227405
Provider Name (Legal Business Name): OLUWAMUTIWA AKINADE DAVID
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2023
Last Update Date: 11/20/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 NORTHFIELD AVE
STATEN ISLAND NY
10303-1624
US

IV. Provider business mailing address

21 NORTHFIELD AVE
STATEN ISLAND NY
10303-1624
US

V. Phone/Fax

Practice location:
  • Phone: 718-316-1736
  • Fax: 718-978-0032
Mailing address:
  • Phone: 718-316-1736
  • Fax: 718-978-0032

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number337679
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: