Provider Demographics
NPI:1952378283
Name:ODULATE, AYODALE SAMUELLA (MD)
Entity Type:Individual
Prefix:DR
First Name:AYODALE
Middle Name:SAMUELLA
Last Name:ODULATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AYODALE
Other - Middle Name:SAMUELLA
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3660 ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3912
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7601 PIONEERS BLVD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-4675
Practice Address - Country:US
Practice Address - Phone:402-484-6677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-06
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA225130208D00000X
CAA1043642085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice