Basic Information
| Provider Information | |||||||||
| NPI: | 1073074969 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AWONIYI | ||||||||
| FirstName: | OLASUMBO | ||||||||
| MiddleName: | OMOWONUOLA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD,MPH | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SOYOOLA | ||||||||
| OtherFirstName: | OLASUMBO | ||||||||
| OtherMiddleName: | OMOWONUOLA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD,MPH | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 230 E RIDGEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076524142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019674000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 230 E RIDGEWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | PARAMUS | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076524142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2019674000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/25/2019 | ||||||||
| LastUpdateDate: | 10/12/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MA11326400 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.