Provider Demographics
NPI:1336611128
Name:IKOTUN, TAYE TOPE SR
Entity Type:Individual
Prefix:
First Name:TAYE
Middle Name:TOPE
Last Name:IKOTUN
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 NORTON ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4343
Mailing Address - Country:US
Mailing Address - Phone:401-288-8172
Mailing Address - Fax:
Practice Address - Street 1:15 NORTON ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4343
Practice Address - Country:US
Practice Address - Phone:401-288-8172
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI3195748172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver