Provider Demographics
NPI:1306814033
Name:ODUNSI, OLASUPO ADEWALE (MD)
Entity Type:Individual
Prefix:
First Name:OLASUPO
Middle Name:ADEWALE
Last Name:ODUNSI
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 1:7513 NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:TAKOMA PARK
Mailing Address - State:MD
Mailing Address - Zip Code:20912-6969
Mailing Address - Country:US
Mailing Address - Phone:301-434-0075
Mailing Address - Fax:301-434-0151
Practice Address - Street 1:7513 NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:TAKOMA PARK
Practice Address - State:MD
Practice Address - Zip Code:20912-6969
Practice Address - Country:US
Practice Address - Phone:301-434-0075
Practice Address - Fax:301-434-0151
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-09
Last Update Date:2011-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0052125207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDG86526Medicare UPIN