Provider Demographics
NPI:1306129341
Name:OSOFISAN, OLATUNDE (DPM)
Entity type:Individual
Prefix:DR
First Name:OLATUNDE
Middle Name:
Last Name:OSOFISAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:295 THROOP AVE
Mailing Address - Street 2:APT 1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-7121
Mailing Address - Country:US
Mailing Address - Phone:917-826-7794
Mailing Address - Fax:718-613-6527
Practice Address - Street 1:1545 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-1122
Practice Address - Country:US
Practice Address - Phone:718-613-7005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-26
Last Update Date:2011-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR76156213ES0000X, 213E00000X, 213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine