Provider Demographics
NPI:1114713054
Name:OLASUPO, OLUTAYO OLAIDE (MD)
Entity type:Individual
Prefix:DR
First Name:OLUTAYO
Middle Name:OLAIDE
Last Name:OLASUPO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 BEACH 20TH ST
Mailing Address - Street 2:
Mailing Address - City:FAR ROCKAWAY
Mailing Address - State:NY
Mailing Address - Zip Code:11691-3615
Mailing Address - Country:US
Mailing Address - Phone:718-327-7307
Mailing Address - Fax:718-327-3294
Practice Address - Street 1:529 BEACH 20TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3615
Practice Address - Country:US
Practice Address - Phone:718-327-7307
Practice Address - Fax:718-327-3294
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-17
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP128167207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty