Provider Demographics
NPI:1801122114
Name:ITABIYI, OLADIPO O (OD)
Entity type:Individual
Prefix:DR
First Name:OLADIPO
Middle Name:O
Last Name:ITABIYI
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1641
Mailing Address - Street 2:
Mailing Address - City:BROOKHAVEN
Mailing Address - State:PA
Mailing Address - Zip Code:19015-0641
Mailing Address - Country:US
Mailing Address - Phone:610-505-9618
Mailing Address - Fax:
Practice Address - Street 1:1234 HARSHAW RD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:PA
Practice Address - Zip Code:19015-1908
Practice Address - Country:US
Practice Address - Phone:610-876-1744
Practice Address - Fax:610-876-1744
Is Sole Proprietor?:No
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG002206152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist