Provider Demographics
NPI:1760769699
Name:OTULANA, OLAKUMBI B (DO)
Entity Type:Individual
Prefix:DR
First Name:OLAKUMBI
Middle Name:B
Last Name:OTULANA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR STE 120
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6850
Practice Address - Country:US
Practice Address - Phone:803-434-8866
Practice Address - Fax:803-933-3049
Is Sole Proprietor?:No
Enumeration Date:2011-11-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP1381207R00000X, 207RG0100X
SC39915207RG0100X
IL036.143709207RG0100X
MI5101025775207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC399152Medicaid