Provider Demographics
NPI:1891360525
Name:OWOLABI, MODUPEOLUWA (MD)
Entity Type:Individual
Prefix:DR
First Name:MODUPEOLUWA
Middle Name:
Last Name:OWOLABI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 CENTRAL AVE FL D7
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07102-1909
Mailing Address - Country:US
Mailing Address - Phone:973-877-5465
Mailing Address - Fax:
Practice Address - Street 1:111 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-1909
Practice Address - Country:US
Practice Address - Phone:678-849-4198
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ390200000X390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program