Provider Demographics
NPI:1083250484
Name:OLADERU, OLASUMBO
Entity Type:Individual
Prefix:
First Name:OLASUMBO
Middle Name:
Last Name:OLADERU
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 1:4 BOLEYN CT
Mailing Address - Street 2:
Mailing Address - City:EWING
Mailing Address - State:NJ
Mailing Address - Zip Code:08628-2231
Mailing Address - Country:US
Mailing Address - Phone:609-321-0233
Mailing Address - Fax:
Practice Address - Street 1:1901 N OLDEN AVENUE EXT STE 11A
Practice Address - Street 2:
Practice Address - City:EWING
Practice Address - State:NJ
Practice Address - Zip Code:08618-2100
Practice Address - Country:US
Practice Address - Phone:609-583-4969
Practice Address - Fax:609-323-7285
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-20
Last Update Date:2022-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00987800363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0751171Medicaid