Provider Demographics
NPI:1922140011
Name:IYEWARUN, OLATUNBOSUN MODUPE (PT)
Entity Type:Individual
Prefix:MISS
First Name:OLATUNBOSUN
Middle Name:MODUPE
Last Name:IYEWARUN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3901 UNIVERSITY BLVD S
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4312
Mailing Address - Country:US
Mailing Address - Phone:904-306-8976
Mailing Address - Fax:904-306-8978
Practice Address - Street 1:3901 UNIVERSITY BLVD S
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4312
Practice Address - Country:US
Practice Address - Phone:904-306-8976
Practice Address - Fax:904-306-8978
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT 11075225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist