Provider Demographics
NPI:1689660151
Name:ODUSANYA, ABIMBOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:ABIMBOLA
Middle Name:
Last Name:ODUSANYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:ABIMBOLA
Other - Middle Name:
Other - Last Name:SHAFAU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11131 MANDERLY LN
Mailing Address - Street 2:
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33467-7404
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13001 SOUTHERN BLVD
Practice Address - Street 2:
Practice Address - City:LOXAHATCHEE
Practice Address - State:FL
Practice Address - Zip Code:33470-9203
Practice Address - Country:US
Practice Address - Phone:561-798-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 82368208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL06025OtherMEDICARE CORE
FL06025OtherMEDICARE CORE
G59825Medicare UPIN