Healthcare Provider Details

I. General information

NPI: 1003549205
Provider Name (Legal Business Name): OLATUNDE KUPONIYI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2022
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 WALNUT ST
PHILADELPHIA PA
19107-5191
US

IV. Provider business mailing address

901 WALNUT ST
PHILADELPHIA PA
19107-5214
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-7000
  • Fax:
Mailing address:
  • Phone: 215-955-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS024086
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: