Provider Demographics
NPI:1588070346
Name:BOSU, OLATUNDE
Entity type:Individual
Prefix:
First Name:OLATUNDE
Middle Name:
Last Name:BOSU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39407 VISTA DEL SOL
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3283
Mailing Address - Country:US
Mailing Address - Phone:760-773-4130
Mailing Address - Fax:760-773-1374
Practice Address - Street 1:39407 VISTA DEL SOL
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3283
Practice Address - Country:US
Practice Address - Phone:760-773-4130
Practice Address - Fax:607-773-1374
Is Sole Proprietor?:No
Enumeration Date:2014-07-01
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD462235207Q00000X
CAA177863207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine