Provider Demographics
NPI:1316050750
Name:OLUTADE, BABATUNDE (MD)
Entity type:Individual
Prefix:DR
First Name:BABATUNDE
Middle Name:
Last Name:OLUTADE
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 1:5903 RIDGEWOOD RD
Mailing Address - Street 2:SUITE 340
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39211-3700
Mailing Address - Country:US
Mailing Address - Phone:601-899-3340
Mailing Address - Fax:601-899-3343
Practice Address - Street 1:5903 RIDGEWOOD RD
Practice Address - Street 2:SUITE 340
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-3700
Practice Address - Country:US
Practice Address - Phone:601-899-3340
Practice Address - Fax:601-899-3343
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS015731207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS0119520Medicaid
MS0119520Medicaid