1003854449 NPI number — ISIAKA OLAWALE SHOLABI MD

Table of content: ISIAKA OLAWALE SHOLABI MD (NPI 1003854449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003854449 NPI number — ISIAKA OLAWALE SHOLABI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SHOLABI
Provider First Name:
ISIAKA
Provider Middle Name:
OLAWALE
Provider Name Prefix Text:
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:
1003854449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/19/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
381 BROAD ST APT 707A
Provider Second Line Business Mailing Address:
NEWARK,NJ
Provider Business Mailing Address City Name:
NEWARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07104-5314
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:
646-417-1127

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3050 COMMERCE DR
Provider Second Line Business Practice Location Address:
SUITE C CREDENTIALS
Provider Business Practice Location Address City Name:
FORT GRATIOT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48059-3819
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
810-385-8086
Provider Business Practice Location Address Fax Number:
810-385-4933
Provider Enumeration Date:
06/04/2006

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: 208M00000X , with the licence number:  4301087339 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 061654 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 4301087339 . This is a "PHYSICIAN LICENSE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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