Basic Information
| Provider Information | |||||||||
| NPI: | 1790047942 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AYODELE OKUNOLA MD CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4102 | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894324102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024533799 | ||||||||
| FaxNumber: | 7024535741 | ||||||||
| Practice Location | |||||||||
| Address1: | 85 SIERRA PARK RD | ||||||||
| Address2: | |||||||||
| City: | MAMMOTH LAKES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935462073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609343311 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2012 | ||||||||
| LastUpdateDate: | 06/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | LABRECQUE | ||||||||
| AuthorizedOfficialFirstName: | LORI | ||||||||
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| AuthorizedOfficialTitleorPosition: | ACCTS MGR | ||||||||
| AuthorizedOfficialTelephone: | 7024533799 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | A119344 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | A119344 | 01 | CA | CA LIC | OTHER | 13936 | 01 | NV | NV LIC | OTHER |