Provider Demographics
NPI:1669769337
Name:MAKINDE, ABIMBOLU S (MD)
Entity type:Individual
Prefix:DR
First Name:ABIMBOLU
Middle Name:S
Last Name:MAKINDE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19110 BOTHELL WAY NE STE 102
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-2970
Mailing Address - Country:US
Mailing Address - Phone:425-286-8271
Mailing Address - Fax:425-491-7271
Practice Address - Street 1:19110 BOTHELL WAY NE STE 102
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-2970
Practice Address - Country:US
Practice Address - Phone:425-286-8271
Practice Address - Fax:425-286-8271
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-01
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60465979207Q00000X, 207QS0010X
AZ47434207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR72478OtherTRAINING PERMIT