Basic Information
| Provider Information | |||||||||
| NPI: | 1477561066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OBASANYA-EYITAYO | ||||||||
| FirstName: | OLUTOSIN | ||||||||
| MiddleName: | O | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OBASANYA | ||||||||
| OtherFirstName: | OLUTOSIN | ||||||||
| OtherMiddleName: | O | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 17404 140TH AVE | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114344600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7187120551 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2465 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100257486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2128772525 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 026154 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 026154 | 01 | NY | LICENSE NUMBER | OTHER |