Provider Demographics
NPI:1558117218
Name:ODEYEMI, OLUWATAYO
Entity type:Individual
Prefix:
First Name:OLUWATAYO
Middle Name:
Last Name:ODEYEMI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14249 LAKE LODGE DR
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77384-1539
Mailing Address - Country:US
Mailing Address - Phone:940-231-6643
Mailing Address - Fax:
Practice Address - Street 1:14249 LAKE LODGE DR
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-1539
Practice Address - Country:US
Practice Address - Phone:940-231-6643
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-24
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X
TX1058973163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No172A00000XOther Service ProvidersDriver