Provider Demographics
NPI:1134491830
Name:ODOFIN, OLAOLUWA MARY (MD)
Entity Type:Individual
Prefix:
First Name:OLAOLUWA
Middle Name:MARY
Last Name:ODOFIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 CHATEAU DR SW
Mailing Address - Street 2:SUITE 220
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6436
Mailing Address - Country:US
Mailing Address - Phone:256-881-1989
Mailing Address - Fax:
Practice Address - Street 1:250 CHATEAU DR SW
Practice Address - Street 2:SUITE 220
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6436
Practice Address - Country:US
Practice Address - Phone:256-881-1989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AL31854207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program