Provider Demographics
NPI:1417469404
Name:MAKSPORTSMD
Entity Type:Organization
Organization Name:MAKSPORTSMD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ABIMBOLU
Authorized Official - Middle Name:
Authorized Official - Last Name:MAKINDE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-286-8271
Mailing Address - Street 1:19110 BOTHELL WAY NE STE 102
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-2970
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19110 BOTHELL WAY NE STE 102
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-2970
Practice Address - Country:US
Practice Address - Phone:425-286-8271
Practice Address - Fax:425-491-7271
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-30
Last Update Date:2017-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60465979207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty