Healthcare Provider Details

I. General information

NPI: 1679730204
Provider Name (Legal Business Name): OLUWASOLA OLAMIKAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2008
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

1935 MEDICAL DISTRICT DR DEPARTMENT OF ANESTHESIOLOGY
DALLAS TX
75235-7701
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-2000
  • Fax: 360-414-7638
Mailing address:
  • Phone: 214-456-6393
  • Fax: 214-456-7232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberP1378
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberP1378
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License NumberMD60125703
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License NumberP1378
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberMD60125703
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: