1720291339 NPI number — DR. MODUPE TEMIDAYO AWONUGA M.B.B.S

Table of content: DR. MODUPE TEMIDAYO AWONUGA M.B.B.S (NPI 1720291339)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720291339 NPI number — DR. MODUPE TEMIDAYO AWONUGA M.B.B.S

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AWONUGA
Provider First Name:
MODUPE
Provider Middle Name:
TEMIDAYO
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.B.B.S
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
KUYEBI
Provider Other First Name:
MODUPE
Provider Other Middle Name:
TEMIDAYO
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.B.B.S
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1720291339
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
804 SERVICE RD
Provider Second Line Business Mailing Address:
A201
Provider Business Mailing Address City Name:
EAST LANSING
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48824-7015
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
517-884-2976
Provider Business Mailing Address Fax Number:
517-432-3928

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1215 E MICHIGAN AVE
Provider Second Line Business Practice Location Address:
SPARROW HOSPITAL - NEONATOLOGY
Provider Business Practice Location Address City Name:
LANSING
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48912-1811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
517-364-2188
Provider Business Practice Location Address Fax Number:
517-364-3994
Provider Enumeration Date:
05/08/2007

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: 2080N0001X , with the licence number:  055407 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2080N0001X , with the licence number: 4301089600 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1720291339 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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