Provider Demographics
NPI:1366548919
Name:GANIYU, OLALEKAN LUKMAN (PT, MHSC, MTC)
Entity type:Individual
Prefix:
First Name:OLALEKAN
Middle Name:LUKMAN
Last Name:GANIYU
Suffix:
Gender:M
Credentials:PT, MHSC, MTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W SILVER SPRING DR
Mailing Address - Street 2:STE A
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-4218
Mailing Address - Country:US
Mailing Address - Phone:608-368-9783
Mailing Address - Fax:608-368-9784
Practice Address - Street 1:2500 W SILVER SPRING DR
Practice Address - Street 2:STE A
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53209-4218
Practice Address - Country:US
Practice Address - Phone:608-368-9783
Practice Address - Fax:608-368-9784
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI024- 5648261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40403900Medicaid
WI81052Medicare ID - Type Unspecified