Provider Demographics
NPI:1164712774
Name:KOLAWOLE, OLUFEMI
Entity Type:Individual
Prefix:MR
First Name:OLUFEMI
Middle Name:
Last Name:KOLAWOLE
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 1:2201 E ANAHEIM ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-3411
Mailing Address - Country:US
Mailing Address - Phone:562-434-1000
Mailing Address - Fax:562-434-5050
Practice Address - Street 1:2201 E ANAHEIM ST
Practice Address - Street 2:SUITE 101
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3411
Practice Address - Country:US
Practice Address - Phone:562-434-1000
Practice Address - Fax:562-434-5050
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-15
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54393332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5963570001Medicare NSC