Provider Demographics
NPI:1396369195
Name:OBAKPOLOR, IKPONMWOSA (DPT)
Entity Type:Individual
Prefix:DR
First Name:IKPONMWOSA
Middle Name:
Last Name:OBAKPOLOR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 RIVERVIEW PL # 808
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30238-2202
Mailing Address - Country:US
Mailing Address - Phone:770-605-1297
Mailing Address - Fax:
Practice Address - Street 1:234 VILLAGE DRIVE
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253
Practice Address - Country:US
Practice Address - Phone:770-954-9631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist