Provider Demographics
NPI:1437137932
Name:IDEWU, OLAWALE O (MD)
Entity Type:Individual
Prefix:
First Name:OLAWALE
Middle Name:O
Last Name:IDEWU
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 1:103 W MARION AVE
Mailing Address - Street 2:
Mailing Address - City:PUNTA GORDA
Mailing Address - State:FL
Mailing Address - Zip Code:33950-4403
Mailing Address - Country:US
Mailing Address - Phone:941-205-5555
Mailing Address - Fax:941-205-5558
Practice Address - Street 1:103 W MARION AVE
Practice Address - Street 2:
Practice Address - City:PUNTA GORDA
Practice Address - State:FL
Practice Address - Zip Code:33950-4403
Practice Address - Country:US
Practice Address - Phone:941-205-5555
Practice Address - Fax:941-205-5558
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME80223207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLC42010Medicare UPIN