Provider Demographics
NPI:1780655175
Name:BABALOLA, EBENEZER O (MD)
Entity Type:Individual
Prefix:
First Name:EBENEZER
Middle Name:O
Last Name:BABALOLA
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 1:6 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4079
Mailing Address - Country:US
Mailing Address - Phone:631-444-4686
Mailing Address - Fax:631-444-4622
Practice Address - Street 1:811 W INTERSTATE 20 STE 114
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76017-5871
Practice Address - Country:US
Practice Address - Phone:817-784-8268
Practice Address - Fax:817-804-8178
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY277987207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyFemale Pelvic Medicine and Reconstructive Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080950100Medicaid
KS200613020AMedicaid
MN080950100Medicaid
H02166Medicare UPIN
MN160002246Medicare ID - Type Unspecified
MNP00042775Medicare ID - Type UnspecifiedRAILROAD