Provider Demographics
NPI:1184822181
Name:OLISA, OBIDIKE M (MD)
Entity Type:Individual
Prefix:
First Name:OBIDIKE
Middle Name:M
Last Name:OLISA
Suffix:
Gender:M
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:N10565 GRANDVIEW LN
Mailing Address - Street 2:
Mailing Address - City:IRONWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49938-9622
Mailing Address - Country:US
Mailing Address - Phone:906-932-1500
Mailing Address - Fax:906-932-5630
Practice Address - Street 1:N10565 GRANDVIEW LN
Practice Address - Street 2:
Practice Address - City:IRONWOOD
Practice Address - State:MI
Practice Address - Zip Code:49938-9622
Practice Address - Country:US
Practice Address - Phone:906-932-1500
Practice Address - Fax:906-932-5630
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301090895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOO090895OtherBLUE CROSS BLUE SHIELD MI
MI5208906Medicaid
WI34934900Medicaid