Provider Demographics
NPI:1396961967
Name:OMORUYI, OSAWARU JUDE (MD)
Entity type:Individual
Prefix:DR
First Name:OSAWARU
Middle Name:JUDE
Last Name:OMORUYI
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 1:2202 BUECHEL AVE
Mailing Address - Street 2:STE 105
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40218-2672
Mailing Address - Country:US
Mailing Address - Phone:502-456-0494
Mailing Address - Fax:502-456-0496
Practice Address - Street 1:2202 BUECHEL AVE
Practice Address - Street 2:STE 105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40218-2672
Practice Address - Country:US
Practice Address - Phone:502-367-3360
Practice Address - Fax:502-367-3365
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.088666207Q00000X
IN01066757A207QG0300X
KY42023207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN2009500930Medicaid
KY7100072730Medicaid
KY7100072730Medicaid
KYP00789580Medicare PIN