Provider Demographics
NPI:1679126296
Name:OLADITAN, MARY ABIODUN (LPP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ABIODUN
Last Name:OLADITAN
Suffix:
Gender:F
Credentials:LPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10453-4303
Mailing Address - Country:US
Mailing Address - Phone:718-618-0401
Mailing Address - Fax:347-479-1303
Practice Address - Street 1:1436 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2507
Practice Address - Country:US
Practice Address - Phone:646-759-5453
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY09669391208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice