Basic Information
| Provider Information | |||||||||
| NPI: | 1679914493 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDOWU | ||||||||
| FirstName: | BENMICHAEL | ||||||||
| MiddleName: | OLUSOLA | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 565 COAL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON HILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122676810 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 565 COAL VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON HILLS | ||||||||
| State: | PA | ||||||||
| PostalCode: | 150253703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4122676810 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 58.005283 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | OS018160 | PA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.