Provider Demographics
NPI:1356335418
Name:OSOBAMIRO, ABIMBOLA MODUPE (MD)
Entity type:Individual
Prefix:DR
First Name:ABIMBOLA
Middle Name:MODUPE
Last Name:OSOBAMIRO
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:PO BOX 675398
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-5398
Mailing Address - Country:US
Mailing Address - Phone:586-329-1880
Mailing Address - Fax:586-231-0055
Practice Address - Street 1:133 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2308
Practice Address - Country:US
Practice Address - Phone:586-468-1600
Practice Address - Fax:586-465-0329
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301063170207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4846450Medicaid
MI70-0-F32947-0OtherBCBS CPIN #
MIAO063170OtherBCBSM
MI1356335418OtherNPI #
G55967Medicare UPIN
MI4846450Medicaid