MEDICARE: DR. OLUWAFEMI DAVID JIMOH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	P112406	NY

General Provider Information

NPI Number	:	1215692611
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. OLUWAFEMI DAVID JIMOH MD

Provider Business Mailing Address
First Line	:	4620 N BANNER DR APT 1
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-1721
Country	:	US
Telephone Number	:	562-313-1188
Fax Number	:

Provider Business Practice Location Address
First Line	:	2830 PITKIN AVE
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11208-3220
Country	:	US
Telephone Number	:	310-709-1236
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2021
Last Update Date	:	11/01/2021

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