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General NPI Number Information
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NPI Number | 1225304009
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Entity Type | Organization
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Legal Business Name | EAR,NOSE AND THROAT HEALTH CENTER, LLC
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Dates
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Enumeration Date | 03/27/2012
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Last Update Date | 08/23/2012
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Provider Practice Location Address
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Address Line | 103 W MARION AVE
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City | PUNTA GORDA
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State | FL
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Zip | 33950-4403
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Country | US
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Telephone | 941-205-5555
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Fax | 941-205-5558
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Provider Business Mailing Address
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Address Line | 103 W MARION AVE
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City | PUNTA GORDA
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State | FL
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Zip | 33950-4403
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Country | US
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Telephone | 941-205-5555
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Fax | 941-205-5558
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Authorized Official
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Title or Position | OWNER
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Name | DR. OLAWALE OLUSOJI IDEWU
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Credential | M.D.
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Telephone | 941-205-5555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Y00000X
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Taxonomy Name | Otolaryngology Physician
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License Number | ME80223
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License Number State | FL
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