Provider Demographics
NPI:1619402021
Name:BARUWA ETTI, ABISOLA GBEMISOLA
Entity Type:Individual
Prefix:
First Name:ABISOLA
Middle Name:GBEMISOLA
Last Name:BARUWA ETTI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ABISOLA
Other - Middle Name:GBEMISOLA
Other - Last Name:ALUKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-1921
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1956
Practice Address - Country:US
Practice Address - Phone:860-679-4477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-23
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT064925207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program