Basic Information
| Provider Information | |||||||||
| NPI: | 1629531090 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ONI | ||||||||
| FirstName: | BUKOLA | ||||||||
| MiddleName: | LOLA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1290 SILAS DEANE HWY | ||||||||
| Address2: | HARTFORD HEALTHCARE-CVO | ||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061094337 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 445 S MAIN ST | ||||||||
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| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061101646 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606962200 | ||||||||
| FaxNumber: | 8605617272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 08/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | AR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 71983 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.