Provider Demographics
NPI:1710088349
Name:AIYEGBUSI, MODUPE A (MD)
Entity Type:Individual
Prefix:DR
First Name:MODUPE
Middle Name:A
Last Name:AIYEGBUSI
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Gender:F
Credentials:MD
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Mailing Address - Street 1:3661 TORRANCE BLVD
Mailing Address - Street 2:STE 103
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-4887
Mailing Address - Country:US
Mailing Address - Phone:310-540-7240
Mailing Address - Fax:310-540-7280
Practice Address - Street 1:21350 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 157
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5605
Practice Address - Country:US
Practice Address - Phone:310-540-7240
Practice Address - Fax:310-540-7280
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2017-03-23
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Provider Licenses
StateLicense IDTaxonomies
CAA65390207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A653900Medicaid
CA00A653900Medicaid
CAF40545Medicare UPIN