Basic Information
| Provider Information | |||||||||
| NPI: | 1073878419 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLORUNDAMI | ||||||||
| FirstName: | OLUBUNMI | ||||||||
| MiddleName: | ABIOLA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | N52W16611 OAK RIDGE TRL | ||||||||
| Address2: | |||||||||
| City: | MENOMONEE FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530510642 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624398675 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4855 S MOORLAND RD | ||||||||
| Address2: | URGENT CARE CLINIC - 3RD FLOOR | ||||||||
| City: | NEW BERLIN | ||||||||
| State: | WI | ||||||||
| PostalCode: | 531517494 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2624327599 | ||||||||
| FaxNumber: | 2624327694 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2012 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 63946 | WI | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1073878419 | 05 | WI | MEDICAID |