Provider Demographics
NPI:1104890854
Name:ODUMOSU, OLADAPO O (MD)
Entity type:Individual
Prefix:DR
First Name:OLADAPO
Middle Name:O
Last Name:ODUMOSU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28248 N TATUM BLVD
Mailing Address - Street 2:BLDG B-1 #605
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-6343
Mailing Address - Country:US
Mailing Address - Phone:602-996-5595
Mailing Address - Fax:602-996-5610
Practice Address - Street 1:28248 N TATUM BLVD
Practice Address - Street 2:BLDG B-1 #605
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-6343
Practice Address - Country:US
Practice Address - Phone:602-996-5595
Practice Address - Fax:602-996-5610
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2013-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ30700OtherMEDICAL LICENSE
AZ724543Medicaid
AZ30700OtherMEDICAL LICENSE
AZ724543Medicaid