Provider Demographics
NPI:1477561066
Name:OBASANYA-EYITAYO, OLUTOSIN O (PT)
Entity Type:Individual
Prefix:MRS
First Name:OLUTOSIN
Middle Name:O
Last Name:OBASANYA-EYITAYO
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:OLUTOSIN
Other - Middle Name:O
Other - Last Name:OBASANYA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:17404 140TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-4600
Mailing Address - Country:US
Mailing Address - Phone:718-712-0551
Mailing Address - Fax:
Practice Address - Street 1:2465 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-7486
Practice Address - Country:US
Practice Address - Phone:212-877-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY026154225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY026154OtherLICENSE NUMBER