Provider Demographics
NPI:1316333040
Name:SAMUEL, OLUWASEUN BOLA (MD)
Entity type:Individual
Prefix:DR
First Name:OLUWASEUN
Middle Name:BOLA
Last Name:SAMUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 N COUNTY ROAD 25A
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-4000
Mailing Address - Fax:
Practice Address - Street 1:3130 N COUNTY ROAD 25A
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-09
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2018-01742208M00000X
390200000X
OH35.143484208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program