Provider Demographics
NPI:1740593896
Name:SODIPO, OLUBUNMI
Entity Type:Individual
Prefix:MS
First Name:OLUBUNMI
Middle Name:
Last Name:SODIPO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 HARBOR LOOP
Mailing Address - Street 2:APT# A
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10303-1873
Mailing Address - Country:US
Mailing Address - Phone:718-815-0767
Mailing Address - Fax:
Practice Address - Street 1:70 HARBOR LOOP
Practice Address - Street 2:APT# A
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10303-1873
Practice Address - Country:US
Practice Address - Phone:718-815-0767
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-19
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY300565164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY300871Medicaid
NY300871Medicaid
3008197139Medicare Oscar/Certification
3008197139Medicare NSC