Provider Demographics
NPI:1336139617
Name:AWODELE, OLATOKUNBO OLUFUNMIKE (MD)
Entity Type:Individual
Prefix:DR
First Name:OLATOKUNBO
Middle Name:OLUFUNMIKE
Last Name:AWODELE
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:PO BOX 34729
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68134-0729
Mailing Address - Country:US
Mailing Address - Phone:402-505-6900
Mailing Address - Fax:402-991-5419
Practice Address - Street 1:1941 S 42ND ST
Practice Address - Street 2:SUITE 434
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68105-2939
Practice Address - Country:US
Practice Address - Phone:402-505-6900
Practice Address - Fax:402-991-5419
Is Sole Proprietor?:No
Enumeration Date:2005-10-26
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE21436207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025134800Medicaid
201352833OtherTAX ID NUMBER
09957Medicare PIN
H28070Medicare UPIN
NE10025134800Medicaid