Provider Demographics
NPI:1063756096
Name:OLUMUYIDE, OLUSEGUN O (LPN)
Entity type:Individual
Prefix:MR
First Name:OLUSEGUN
Middle Name:O
Last Name:OLUMUYIDE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 OLINVILLE AVE APT G
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-7478
Mailing Address - Country:US
Mailing Address - Phone:212-786-2564
Mailing Address - Fax:
Practice Address - Street 1:2545 OLINVILLE AVE APT G
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-7478
Practice Address - Country:US
Practice Address - Phone:212-786-2564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3041081164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse