Healthcare Provider Details

I. General information

NPI: 1073878419
Provider Name (Legal Business Name): OLUBUNMI ABIOLA OLORUNDAMI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2012
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4855 S MOORLAND RD URGENT CARE CLINIC - 3RD FLOOR
NEW BERLIN WI
53151-7494
US

IV. Provider business mailing address

N52W16611 OAK RIDGE TRL
MENOMONEE FALLS WI
53051-0642
US

V. Phone/Fax

Practice location:
  • Phone: 262-432-7599
  • Fax: 262-432-7694
Mailing address:
  • Phone: 262-439-8675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number63946
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: