Provider Demographics
NPI:1013955624
Name:ONISILE, OLUDARE (MD)
Entity type:Individual
Prefix:
First Name:OLUDARE
Middle Name:
Last Name:ONISILE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-4006
Mailing Address - Country:US
Mailing Address - Phone:602-222-8727
Mailing Address - Fax:
Practice Address - Street 1:4607 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-4006
Practice Address - Country:US
Practice Address - Phone:602-222-8727
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ23710207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ329286Medicaid
28625Medicare ID - Type Unspecified
G22296Medicare UPIN