1922365279 NPI number — BUKOLA GANIYAT ETA M.D.

Table of content: BUKOLA GANIYAT ETA M.D. (NPI 1922365279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922365279 NPI number — BUKOLA GANIYAT ETA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ETA
Provider First Name:
BUKOLA
Provider Middle Name:
GANIYAT
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
ARIJE
Provider Other First Name:
BUKOLA
Provider Other Middle Name:
GANIYAT
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1922365279
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1521 RAINBOW DR
Provider Second Line Business Mailing Address:
ANESTHESIA ASSOCIATES PA
Provider Business Mailing Address City Name:
GADSDEN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35901-5395
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-546-5281
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1521 RAINBOW DR
Provider Second Line Business Practice Location Address:
ANESTHESIA ASSOCIATES PA
Provider Business Practice Location Address City Name:
GADSDEN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35901-5395
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-546-5281
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/11/2012

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: 207L00000X , with the licence number:  35132 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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