Provider Demographics
NPI:1376957696
Name:ODEJIDE, BOLANLE (RRT)
Entity Type:Individual
Prefix:
First Name:BOLANLE
Middle Name:
Last Name:ODEJIDE
Suffix:
Gender:F
Credentials:RRT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 VILLAGE TRACE DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-6229
Mailing Address - Country:US
Mailing Address - Phone:317-366-7583
Mailing Address - Fax:
Practice Address - Street 1:4247 VILLAGE TRACE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-6229
Practice Address - Country:US
Practice Address - Phone:317-366-7583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-14
Last Update Date:2014-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN30008466A227900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes227900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, Registered