Provider Demographics
NPI:1598296758
Name:OKUNDAYE, ETINOSASERE
Entity type:Individual
Prefix:
First Name:ETINOSASERE
Middle Name:
Last Name:OKUNDAYE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 S STILES ST APT 4
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4339
Mailing Address - Country:US
Mailing Address - Phone:951-447-9921
Mailing Address - Fax:
Practice Address - Street 1:500 UPPER CHESAPEAKE DR
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21014-4324
Practice Address - Country:US
Practice Address - Phone:443-643-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFO9573836207R00000X
MDD93506207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine