Basic Information
| Provider Information | |||||||||
| NPI: | 1891773289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLADIPUPO | ||||||||
| FirstName: | OLUWATOSIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25137 | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | IL | ||||||||
| PostalCode: | 625255137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008976169 | ||||||||
| FaxNumber: | 8008976170 | ||||||||
| Practice Location | |||||||||
| Address1: | 1133 EAGLES LANDING PKWY | ||||||||
| Address2: | |||||||||
| City: | STOCKBRIDGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302815085 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6786041053 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 11/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 036-110320 | IL | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | 93451 | GA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 036110320 | 05 | IL | MEDICAID | 036110320 | 01 | IL | BC OF IL | OTHER |