Provider Demographics
NPI:1649297573
Name:OYEMADE, OLUSOLA A (MD)
Entity type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:A
Last Name:OYEMADE
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 1:7777 MILLIKEN AVE
Mailing Address - Street 2:SUITE 360
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-6780
Mailing Address - Country:US
Mailing Address - Phone:909-944-7099
Mailing Address - Fax:909-944-4865
Practice Address - Street 1:7777 MILLIKEN AVE
Practice Address - Street 2:SUITE 360
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6780
Practice Address - Country:US
Practice Address - Phone:909-944-7099
Practice Address - Fax:909-944-4865
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA025950208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A259501Medicaid
CA00A259501Medicaid