Provider Demographics
NPI:1962826768
Name:TUNDE OSOFISAN, DPM P.C.
Entity type:Organization
Organization Name:TUNDE OSOFISAN, DPM P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TUNDE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSOFISAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-826-7794
Mailing Address - Street 1:295 THROOP AVE
Mailing Address - Street 2:1B
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11206-7121
Mailing Address - Country:US
Mailing Address - Phone:917-826-7794
Mailing Address - Fax:718-613-4898
Practice Address - Street 1:295 THROOP AVE
Practice Address - Street 2:1B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-7121
Practice Address - Country:US
Practice Address - Phone:917-826-7794
Practice Address - Fax:718-613-4898
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-13
Last Update Date:2014-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006467261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03618760Medicaid
NYA300087024Medicare UPIN