Provider Demographics
NPI:1336846542
Name:OLUBIYI, OMOTAYO (PHD)
Entity Type:Individual
Prefix:DR
First Name:OMOTAYO
Middle Name:
Last Name:OLUBIYI
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 SAN PEDRO DR NE STE 2F4-2F5
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-4120
Mailing Address - Country:US
Mailing Address - Phone:505-403-5957
Mailing Address - Fax:
Practice Address - Street 1:2325 SAN PEDRO DR NE STE 2F4-2F5
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-4120
Practice Address - Country:US
Practice Address - Phone:505-403-5957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-08
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPRC58070343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)