=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609952043
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OPTIMUM FAMILY MEDICINE P.C
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/27/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 675 NEREID AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10470-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-202-9545
-----------------------------------------------------
Fax | 347-202-9580
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 675 NEREID AVE
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10470-1514
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 347-202-9545
-----------------------------------------------------
Fax | 347-202-9580
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. OLUFUNMILAYO O ADEYANJU
-----------------------------------------------------
Credential | M.D
-----------------------------------------------------
Telephone | 347-202-9545
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 236764
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------