Provider Demographics
NPI:1003895517
Name:AKANDE, OLUGESIN (PHYSICAL THERAPIST)
Entity Type:Individual
Prefix:MR
First Name:OLUGESIN
Middle Name:
Last Name:AKANDE
Suffix:
Gender:M
Credentials:PHYSICAL THERAPIST
Other - Prefix:MR
Other - First Name:OLUGESIN
Other - Middle Name:
Other - Last Name:AKANDE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSC PHYSICAL THERA
Mailing Address - Street 1:20122 W MCNICHOLS RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-3374
Mailing Address - Country:US
Mailing Address - Phone:313-341-4910
Mailing Address - Fax:313-341-4916
Practice Address - Street 1:20122 W MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-3374
Practice Address - Country:US
Practice Address - Phone:313-538-0140
Practice Address - Fax:313-538-0147
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2018-05-23
Deactivation Date:2007-07-27
Deactivation Code:
Reactivation Date:2008-04-14
Provider Licenses
StateLicense IDTaxonomies
MI5501006358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4132240TYPE10Medicaid
MI650H257430OtherBCBSM ID NUMBER