Provider Demographics
NPI:1043654635
Name:ODUEKUN, IYIOLA
Entity Type:Individual
Prefix:
First Name:IYIOLA
Middle Name:
Last Name:ODUEKUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 W 50TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10020-1201
Mailing Address - Country:US
Mailing Address - Phone:212-582-1900
Mailing Address - Fax:
Practice Address - Street 1:135 W 50TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10020-1201
Practice Address - Country:US
Practice Address - Phone:212-582-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY681940163W00000X
NY313860164W00000X
NY403269363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse