Provider Demographics
NPI:1134516446
Name:AWOSIKA, OLABOLA (MD)
Entity type:Individual
Prefix:
First Name:OLABOLA
Middle Name:
Last Name:AWOSIKA
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 1:5141 VIRGINIA WAY STE 350
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2319
Mailing Address - Country:US
Mailing Address - Phone:855-744-8554
Mailing Address - Fax:630-495-1770
Practice Address - Street 1:37605 PEMBROKE AVE
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1050
Practice Address - Country:US
Practice Address - Phone:834-591-7931
Practice Address - Fax:734-464-0335
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301505497207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program