1386804334 NPI number — DR. EZEKIEL ADEREMI OSUNTOGUN MD

Table of content: DR. EZEKIEL ADEREMI OSUNTOGUN MD (NPI 1386804334)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386804334 NPI number — DR. EZEKIEL ADEREMI OSUNTOGUN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSUNTOGUN
Provider First Name:
EZEKIEL
Provider Middle Name:
ADEREMI
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386804334
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 46577
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAMPA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33646-0105
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
813-727-2650
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13601 BRUCE B DOWNS BLVD
Provider Second Line Business Practice Location Address:
SUIT 121
Provider Business Practice Location Address City Name:
TAMPA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33613-4657
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
813-454-1113
Provider Business Practice Location Address Fax Number:
813-454-1114
Provider Enumeration Date:
06/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207QA0401X , with the licence number:  ME106194 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: ME106194 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100828100 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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