Provider Demographics
NPI:1184735698
Name:SOYODE, OLUFEMI O (MD)
Entity type:Individual
Prefix:
First Name:OLUFEMI
Middle Name:O
Last Name:SOYODE
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 1:422 PLYMOUTH AVE NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49505-6028
Mailing Address - Country:US
Mailing Address - Phone:616-294-0010
Mailing Address - Fax:616-828-1802
Practice Address - Street 1:422 PLYMOUTH AVE NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49505-6028
Practice Address - Country:US
Practice Address - Phone:616-294-0010
Practice Address - Fax:616-828-1802
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2015-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010814202084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1184735698Medicaid
MI1184735698Medicaid