Provider Demographics
NPI:1386911766
Name:OLOWOSUKO, OMOBONIKE (DO)
Entity type:Individual
Prefix:
First Name:OMOBONIKE
Middle Name:
Last Name:OLOWOSUKO
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:2614 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-3828
Practice Address - Country:US
Practice Address - Phone:504-291-5100
Practice Address - Fax:504-291-5125
Is Sole Proprietor?:No
Enumeration Date:2011-11-29
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-46887208100000X
MTMED-PHYS-COM-LIC-123208100000X
TN2968208100000X
MDH0083162208100000X
LA334189208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation