Healthcare Provider Details

I. General information

NPI: 1154390078
Provider Name (Legal Business Name): OLAWALE O OLATUNJI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 04/21/2022
Certification Date: 04/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 STANAFORD RD
BECKLEY WV
25801-3142
US

IV. Provider business mailing address

803 SEMINOLE CIR
MOUNT HOPE WV
25880-8811
US

V. Phone/Fax

Practice location:
  • Phone: 681-207-2055
  • Fax: 681-207-1811
Mailing address:
  • Phone: 606-224-1740
  • Fax: 681-207-1811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number36772
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: