Provider Demographics
NPI:1518951672
Name:OSOBAMIRO, OMOKAYODE A (MD)
Entity Type:Individual
Prefix:
First Name:OMOKAYODE
Middle Name:A
Last Name:OSOBAMIRO
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:PO BOX 82057
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MI
Mailing Address - Zip Code:48308-2057
Mailing Address - Country:US
Mailing Address - Phone:586-228-7433
Mailing Address - Fax:248-693-9204
Practice Address - Street 1:16151 19 MILE RD STE 302
Practice Address - Street 2:
Practice Address - City:CLINTON TWP
Practice Address - State:MI
Practice Address - Zip Code:48038-1159
Practice Address - Country:US
Practice Address - Phone:586-228-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-06
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301059326207RN0300X, 207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI10 4841551Medicaid
MI1105018352OtherBCBSM
MI10 4841551Medicaid
G76099Medicare UPIN