Basic Information
| Provider Information | |||||||||
| NPI: | 1528341609 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ODEYALE | ||||||||
| FirstName: | OLUWAFEMI | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER STREET | ||||||||
| Address2: | 2ND FLOOR CRED DEPT | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 12506 101ST AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH RICHMOND HILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188492900 | ||||||||
| FaxNumber: | 7185595468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2011 | ||||||||
| LastUpdateDate: | 09/23/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 006528 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | N006528 | 01 | NY | LICENSE | OTHER |