Provider Demographics
NPI:1164900205
Name:POPOOLA, OLUSEGUN ADEBISI (MD, MPH, CCRP)
Entity Type:Individual
Prefix:
First Name:OLUSEGUN
Middle Name:ADEBISI
Last Name:POPOOLA
Suffix:
Gender:M
Credentials:MD, MPH, CCRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1545 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-1122
Mailing Address - Country:US
Mailing Address - Phone:718-613-4000
Mailing Address - Fax:
Practice Address - Street 1:1504 TAUB LOOP
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1608
Practice Address - Country:US
Practice Address - Phone:738-733-4501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-31
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361646392084P0800X
TXU04192084P0802X, 2084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program