Provider Demographics
NPI:1740691286
Name:BABALOLA, DAMILOLA I
Entity type:Individual
Prefix:
First Name:DAMILOLA
Middle Name:I
Last Name:BABALOLA
Suffix:
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 1:4000 WELLNESS DRIVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48670
Mailing Address - Country:US
Mailing Address - Phone:989-839-1644
Mailing Address - Fax:989-839-3029
Practice Address - Street 1:4000 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-2000
Practice Address - Country:US
Practice Address - Phone:989-839-1644
Practice Address - Fax:989-839-3029
Is Sole Proprietor?:No
Enumeration Date:2014-05-19
Last Update Date:2017-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301111638207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program