Provider Demographics
NPI:1649845074
Name:OLATUNDE, KUDIRAT BUKOLA (MD)
Entity type:Individual
Prefix:
First Name:KUDIRAT
Middle Name:BUKOLA
Last Name:OLATUNDE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5556 OAKWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:STEVENS POINT
Mailing Address - State:WI
Mailing Address - Zip Code:54482-9164
Mailing Address - Country:US
Mailing Address - Phone:708-539-3715
Mailing Address - Fax:
Practice Address - Street 1:333 PINE RIDGE BLVD
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4187
Practice Address - Country:US
Practice Address - Phone:800-283-2881
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-27
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116035037390200000X
WI83596-20208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2007Q00000XOtherFAMILY MEDICINE