Provider Demographics
NPI:1972980647
Name:OLOWO, GRACE BOLUWAPE (MD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:BOLUWAPE
Last Name:OLOWO
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:HSC L2-155
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8228
Mailing Address - Country:US
Mailing Address - Phone:631-444-4630
Mailing Address - Fax:631-444-4652
Practice Address - Street 1:HSC L2-144
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794
Practice Address - Country:US
Practice Address - Phone:631-444-4630
Practice Address - Fax:631-444-4652
Is Sole Proprietor?:No
Enumeration Date:2015-05-01
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY294393207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine