Provider Demographics
NPI:1770683732
Name:ODUKOYA, ABIMBOLA A (MD)
Entity Type:Individual
Prefix:
First Name:ABIMBOLA
Middle Name:A
Last Name:ODUKOYA
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 1:3741 ROME DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-4490
Mailing Address - Country:US
Mailing Address - Phone:765-607-6160
Mailing Address - Fax:765-607-6161
Practice Address - Street 1:3741 ROME DR
Practice Address - Street 2:SUITE B
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-4490
Practice Address - Country:US
Practice Address - Phone:765-607-6160
Practice Address - Fax:765-607-6161
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2015-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY61002723208000000X
IN01062400A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN01062400AOtherIN STATE LICENSE
NY61002723OtherLICENSE
IN200908770Medicaid
IN940550R2Medicare PIN