Provider Demographics
NPI:1427275049
Name:OMORUYI, ADETOKUNBO OLUKOREDE (MD)
Entity type:Individual
Prefix:DR
First Name:ADETOKUNBO
Middle Name:OLUKOREDE
Last Name:OMORUYI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ADETOKUNBO
Other - Middle Name:OLUKOREDE
Other - Last Name:DAWODU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-3400
Mailing Address - Fax:502-588-3401
Practice Address - Street 1:601 S FLOYD ST
Practice Address - Street 2:STE 403
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1837
Practice Address - Country:US
Practice Address - Phone:502-588-3400
Practice Address - Fax:502-588-3401
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY42024208000000X, 2080P0205X
OH35.0869302080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200919290Medicaid
KY7100062650Medicaid
KY7100062650Medicaid
KYK059760Medicare PIN