Provider Demographics
NPI:1720025513
Name:OLUMOFIN, OLABODE (MD)
Entity Type:Individual
Prefix:DR
First Name:OLABODE
Middle Name:
Last Name:OLUMOFIN
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 1:1801 W 40TH AVE STE 1C
Mailing Address - Street 2:
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6956
Mailing Address - Country:US
Mailing Address - Phone:870-535-4141
Mailing Address - Fax:870-535-4141
Practice Address - Street 1:1801 W 40TH AVE
Practice Address - Street 2:SUITE 1C
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6940
Practice Address - Country:US
Practice Address - Phone:870-535-4141
Practice Address - Fax:870-535-9180
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-3124207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR146619001Medicaid
AR146619001Medicaid
H54997Medicare UPIN