Provider Demographics
NPI:1477677458
Name:OLUWATADE, OLATUNJI JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:OLATUNJI
Middle Name:JONATHAN
Last Name:OLUWATADE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:OLATUNJI
Other - Middle Name:JONATHAN
Other - Last Name:OGUNTADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2080 S FRONTAGE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39180-5328
Mailing Address - Country:US
Mailing Address - Phone:601-262-1000
Mailing Address - Fax:
Practice Address - Street 1:2080 S, FRONTAGE RD.
Practice Address - Street 2:SUITE100
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39180-5883
Practice Address - Country:US
Practice Address - Phone:601-262-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089363207R00000X
MS19904207P00000X, 208M00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1811254Medicaid
MS08108016Medicaid
LA1811254Medicaid