Provider Demographics
NPI:1992847644
Name:AFOLALU, ABISOLA O (MD)
Entity Type:Individual
Prefix:DR
First Name:ABISOLA
Middle Name:O
Last Name:AFOLALU
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 1:2 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2370
Mailing Address - Country:US
Mailing Address - Phone:203-234-6500
Mailing Address - Fax:203-234-6503
Practice Address - Street 1:2 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2370
Practice Address - Country:US
Practice Address - Phone:203-234-6500
Practice Address - Fax:203-234-6503
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044951207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT044951OtherSTATE LICENSE
CT001449512Medicaid
CT001449512Medicaid