Provider Demographics
NPI:1104370477
Name:ODETOLA, OLUWATOBI EZEKIEL (MBBS)
Entity type:Individual
Prefix:
First Name:OLUWATOBI
Middle Name:EZEKIEL
Last Name:ODETOLA
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:605-328-9419
Mailing Address - Fax:
Practice Address - Street 1:820 4TH ST N
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58102-4539
Practice Address - Country:US
Practice Address - Phone:012-346-1617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-04
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125.069415207R00000X, 207RH0003X
NDPT21039207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine