Provider Demographics
NPI:1750447421
Name:IMEVBORE, OLUTAYO TEMITOPE (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUTAYO
Middle Name:TEMITOPE
Last Name:IMEVBORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:CB-2041
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06504-8900
Mailing Address - Country:US
Mailing Address - Phone:203-688-4748
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST # CB-2041
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504-8900
Practice Address - Country:US
Practice Address - Phone:203-688-4748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042354208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT042354OtherCT PHYSICIAN LICENSE
CT001423540Medicaid
CT35237OtherCT CSR
CT35237OtherCT CSR
CT001423540Medicaid
CTBI8890419OtherFED DEA REGISTRATION