Provider Demographics
NPI:1518539790
Name:MAGBAGBEOLA, GBENRO (DC)
Entity Type:Individual
Prefix:DR
First Name:GBENRO
Middle Name:
Last Name:MAGBAGBEOLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 GILDER DR
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:DE
Mailing Address - Zip Code:19720-7632
Mailing Address - Country:US
Mailing Address - Phone:302-593-7023
Mailing Address - Fax:
Practice Address - Street 1:650 PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19702-6369
Practice Address - Country:US
Practice Address - Phone:302-453-4043
Practice Address - Fax:302-453-1348
Is Sole Proprietor?:No
Enumeration Date:2021-07-15
Last Update Date:2021-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0011044111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor