Provider Demographics
NPI:1467403196
Name:BOLARINWA, ISIAKA A (MD)
Entity Type:Individual
Prefix:
First Name:ISIAKA
Middle Name:A
Last Name:BOLARINWA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 KLEMM AVE
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08030-1627
Mailing Address - Country:US
Mailing Address - Phone:856-282-5566
Mailing Address - Fax:856-396-9917
Practice Address - Street 1:822 KLEMM AVE
Practice Address - Street 2:
Practice Address - City:GLOUCESTER CITY
Practice Address - State:NJ
Practice Address - Zip Code:08030-1627
Practice Address - Country:US
Practice Address - Phone:856-282-5566
Practice Address - Fax:856-396-9917
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-15
Last Update Date:2023-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA0726972084P0804X
PAMD-073693-L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD073693-LOtherLICENSE
PAMD073693-LOtherLICENSE
PA060069Medicare ID - Type Unspecified
PAH67165Medicare UPIN