Provider Demographics
NPI:1700805835
Name:OLUBODUN, JOEL O (MD)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:O
Last Name:OLUBODUN
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 1:20 PONTE LN
Mailing Address - Street 2:
Mailing Address - City:NORTH KINGSTOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02852-4755
Mailing Address - Country:US
Mailing Address - Phone:617-361-2166
Mailing Address - Fax:
Practice Address - Street 1:891 HYDE PARK AVE
Practice Address - Street 2:BOSTON PAIN CLINIC & PRIMARY CARE
Practice Address - City:HYDE PARK
Practice Address - State:MA
Practice Address - Zip Code:02136-3267
Practice Address - Country:US
Practice Address - Phone:617-361-2166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA205382207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine