Provider Demographics
NPI:1871682559
Name:ODUNTAN, OMOBOLA (MD)
Entity Type:Individual
Prefix:DR
First Name:OMOBOLA
Middle Name:
Last Name:ODUNTAN
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:PO BOX 100237
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0237
Mailing Address - Country:US
Mailing Address - Phone:352-273-5159
Mailing Address - Fax:352-273-5213
Practice Address - Street 1:1600 SW ARCHER RD
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32610-1436
Practice Address - Country:US
Practice Address - Phone:352-273-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV23921207Q00000X
VA0101241296207Q00000X
FLME133149207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022294000Medicaid