Provider Demographics
NPI:1619321528
Name:OLUKOYA, OLUTAYO
Entity Type:Individual
Prefix:
First Name:OLUTAYO
Middle Name:
Last Name:OLUKOYA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3780 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3610
Mailing Address - Country:US
Mailing Address - Phone:203-870-8987
Mailing Address - Fax:203-870-8988
Practice Address - Street 1:3780 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3610
Practice Address - Country:US
Practice Address - Phone:203-870-8987
Practice Address - Fax:203-870-8988
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-17
Last Update Date:2016-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1216892332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies