Provider Demographics
NPI:1831423003
Name:KASUMU, JAIYEOLA BOLAJI (MSC)
Entity type:Individual
Prefix:MS
First Name:JAIYEOLA
Middle Name:BOLAJI
Last Name:KASUMU
Suffix:
Gender:F
Credentials:MSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10305-1733
Mailing Address - Country:US
Mailing Address - Phone:347-235-3792
Mailing Address - Fax:
Practice Address - Street 1:234 VIRGINIA AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10305-1733
Practice Address - Country:US
Practice Address - Phone:347-235-3792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-22
Last Update Date:2009-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012381208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation