Provider Demographics
NPI:1811105661
Name:FADAHUNSI, ABIMBOLA OLUFUNKE (DPT)
Entity type:Individual
Prefix:DR
First Name:ABIMBOLA
Middle Name:OLUFUNKE
Last Name:FADAHUNSI
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ABIMBOLA
Other - Middle Name:O
Other - Last Name:ESAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:20 FULTON RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:NJ
Mailing Address - Zip Code:08873-2326
Mailing Address - Country:US
Mailing Address - Phone:732-246-2536
Mailing Address - Fax:732-246-0428
Practice Address - Street 1:20 FULTON RD
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:NJ
Practice Address - Zip Code:08873-2326
Practice Address - Country:US
Practice Address - Phone:732-246-2536
Practice Address - Fax:732-246-0428
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00599300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ072085Medicare ID - Type UnspecifiedMEDICARE B