Provider Demographics
NPI:1780815308
Name:ODUNUKAN, OLUFUNSO W (MD)
Entity Type:Individual
Prefix:
First Name:OLUFUNSO
Middle Name:W
Last Name:ODUNUKAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10880
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86304-0880
Mailing Address - Country:US
Mailing Address - Phone:928-759-5874
Mailing Address - Fax:928-458-2039
Practice Address - Street 1:1001 WILLOW CREEK RD STE 2200
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-1614
Practice Address - Country:US
Practice Address - Phone:928-445-6025
Practice Address - Fax:928-778-3026
Is Sole Proprietor?:No
Enumeration Date:2009-07-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV20655207RC0000X
GA80736207RI0011X, 207RI0011X
SD8441208M00000X
390200000X
AZ65997207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV250011662Medicaid
AZ65997OtherARIZONA MEDICAL BOARD
AZ65997OtherARIZONA MEDICAL BOARD
SDS106301Medicare PIN
FLHI752ZMedicare PIN
SD6636360Medicaid