=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720025513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | OLABODE OLUMOFIN M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2006
-----------------------------------------------------
Last Update Date | 10/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1801 W 40TH AVE SUITE 1C
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-6940
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-535-4141
-----------------------------------------------------
Fax | 870-535-9180
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1801 W 40TH AVE STE 1C
-----------------------------------------------------
City | PINE BLUFF
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 71603-6956
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 870-535-4141
-----------------------------------------------------
Fax | 870-535-4141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | E3124
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | E-3124
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------