Provider Demographics
NPI:1942761127
Name:OLULADE, OLUMIDE AYODEJI (MD, PHD)
Entity Type:Individual
Prefix:
First Name:OLUMIDE
Middle Name:AYODEJI
Last Name:OLULADE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 MORTON ST APT 2
Mailing Address - Street 2:
Mailing Address - City:JAMAICA PLAIN
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3700
Mailing Address - Country:US
Mailing Address - Phone:813-486-4474
Mailing Address - Fax:
Practice Address - Street 1:75 FRANCIS ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-6106
Practice Address - Country:US
Practice Address - Phone:617-732-5500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-28
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA2805522085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program