Healthcare Provider Details

I. General information

NPI: 1154941672
Provider Name (Legal Business Name): OLAWALE TEMITOPE ODURU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2020
Last Update Date: 06/04/2022
Certification Date: 06/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 HIGHLAND AVE. UW HOSPITALS & CLINICS
MADISON WI
53792-0001
US

IV. Provider business mailing address

600 HIGHLAND AVE. UW HOSPITALS & CLINICS
MADISON WI
53792-0001
US

V. Phone/Fax

Practice location:
  • Phone: 608-263-6400
  • Fax:
Mailing address:
  • Phone: 608-263-6400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number76986-20
License Number StateWI
# 2
Primary TaxonomyN
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: