Healthcare Provider Details

I. General information

NPI: 1154501500
Provider Name (Legal Business Name): OLUGBENGA B KUTEYI MD, FWACP.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/13/2007
Last Update Date: 11/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8701 W WATERTOWN PLANK RD MCWAH
MILWAUKEE WI
53226-3548
US

IV. Provider business mailing address

9102 W DIXON ST
MILWAUKEE WI
53214-1367
US

V. Phone/Fax

Practice location:
  • Phone: 414-266-3736
  • Fax:
Mailing address:
  • Phone: 414-312-7055
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: