Provider Demographics
NPI:1417106477
Name:SANUSI-AGBABIAKA, OLUSOLA O (MD)
Entity Type:Individual
Prefix:
First Name:OLUSOLA
Middle Name:O
Last Name:SANUSI-AGBABIAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:OLUSOLA
Other - Middle Name:O
Other - Last Name:SANUSI-AGBABIAKA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:451 CLARKSON AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2054
Mailing Address - Country:US
Mailing Address - Phone:718-245-3131
Mailing Address - Fax:
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2054
Practice Address - Country:US
Practice Address - Phone:718-245-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363A00000X
390200000X
NY302725207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program