Provider Demographics
NPI:1699168781
Name:OLUBOBOLA, OLUDOTUN
Entity type:Individual
Prefix:
First Name:OLUDOTUN
Middle Name:
Last Name:OLUBOBOLA
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 1:4675 N 76TH ST
Mailing Address - Street 2:LOWER
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-4723
Mailing Address - Country:US
Mailing Address - Phone:414-837-3134
Mailing Address - Fax:
Practice Address - Street 1:4675 N 76TH ST
Practice Address - Street 2:LOWER
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-4723
Practice Address - Country:US
Practice Address - Phone:414-837-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI0203334172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver