Provider Demographics
NPI:1972529170
Name:OLUSOLA, OLUWOLE OLUSEYI (MD)
Entity Type:Individual
Prefix:DR
First Name:OLUWOLE
Middle Name:OLUSEYI
Last Name:OLUSOLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:920 FREDERICA ST STE 407
Mailing Address - Street 2:P.O. BOX 1876
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42301-3079
Mailing Address - Country:US
Mailing Address - Phone:270-684-1077
Mailing Address - Fax:270-684-1339
Practice Address - Street 1:2008 N GAREY AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-2722
Practice Address - Country:US
Practice Address - Phone:909-623-6131
Practice Address - Fax:909-865-9281
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY30604101YP2500X
CAC1591832084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY1605801Medicare UPIN