Provider Demographics
NPI:1093732950
Name:DESALU, OLABODE OLAOSEBIKAN (MD)
Entity Type:Individual
Prefix:DR
First Name:OLABODE
Middle Name:OLAOSEBIKAN
Last Name:DESALU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:OLABODE
Other - Middle Name:OLAOSEBIKAN
Other - Last Name:OSHODI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 CHILDREN'S WAY
Mailing Address - Street 2:SLOT 844
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72202-3500
Mailing Address - Country:US
Mailing Address - Phone:501-364-2090
Mailing Address - Fax:501-364-3929
Practice Address - Street 1:2601 GENE GEORGE BLVD
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-0845
Practice Address - Country:US
Practice Address - Phone:479-725-6977
Practice Address - Fax:479-725-6577
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2020-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ART2018-031208000000X
LA15345R208000000X
ARE-11228208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1470635Medicaid
AR176387001Medicaid
LA4F895F600Medicare ID - Type Unspecified
LA1470635Medicaid
LA4P167CQ62Medicare PIN