Provider Demographics
NPI:1427210699
Name:OMIWADE, OLUMIDE ANUOLUWA (MBCHB)
Entity Type:Individual
Prefix:DR
First Name:OLUMIDE
Middle Name:ANUOLUWA
Last Name:OMIWADE
Suffix:
Gender:M
Credentials:MBCHB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2251 N SHORE DR STE 100
Mailing Address - Street 2:
Mailing Address - City:RHINELANDER
Mailing Address - State:WI
Mailing Address - Zip Code:54501-6710
Mailing Address - Country:US
Mailing Address - Phone:713-550-7718
Mailing Address - Fax:
Practice Address - Street 1:2251 N SHORE DR STE 100
Practice Address - Street 2:
Practice Address - City:RHINELANDER
Practice Address - State:WI
Practice Address - Zip Code:54501-6710
Practice Address - Country:US
Practice Address - Phone:713-550-7718
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-30
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI55799620207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine