Provider Demographics
NPI:1881441103
Name:ABULATAN, ISAAC TOLULOPE
Entity type:Individual
Prefix:
First Name:ISAAC
Middle Name:TOLULOPE
Last Name:ABULATAN
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 1:11800 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3472
Mailing Address - Country:US
Mailing Address - Phone:586-573-5059
Mailing Address - Fax:
Practice Address - Street 1:11800 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-03
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351052963390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program