Provider Demographics
NPI:1063735199
Name:OLUWOLE, OLUYEMISI
Entity type:Individual
Prefix:
First Name:OLUYEMISI
Middle Name:
Last Name:OLUWOLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 BAYWATER DR
Mailing Address - Street 2:APT 2803
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5724
Mailing Address - Country:US
Mailing Address - Phone:469-865-0789
Mailing Address - Fax:
Practice Address - Street 1:5900 BAYWATER DR
Practice Address - Street 2:APT 2803
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5724
Practice Address - Country:US
Practice Address - Phone:469-865-0789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX296717052171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor