Provider Demographics
NPI:1154390078
Name:OLATUNJI, OLAWALE O (MD)
Entity type:Individual
Prefix:
First Name:OLAWALE
Middle Name:O
Last Name:OLATUNJI
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 1:803 SEMINOLE CIR
Mailing Address - Street 2:
Mailing Address - City:MOUNT HOPE
Mailing Address - State:WV
Mailing Address - Zip Code:25880-8811
Mailing Address - Country:US
Mailing Address - Phone:606-224-1740
Mailing Address - Fax:681-207-1811
Practice Address - Street 1:306 STANAFORD RD
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-3142
Practice Address - Country:US
Practice Address - Phone:681-207-2055
Practice Address - Fax:681-207-1811
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY36772207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64050230Medicaid
000000584950OtherBCBS- CUMBERLAND CLINIC
WV26160OtherWV MEDICAL LICENSE
9369201Medicare ID - Type Unspecified
KY64050230Medicaid
0930807Medicare ID - Type Unspecified
0768607Medicare ID - Type Unspecified
0786707Medicare ID - Type Unspecified
0938505Medicare ID - Type Unspecified
0305825Medicare ID - Type Unspecified