Basic Information
| Provider Information | |||||||||
| NPI: | 1225326853 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ABIODUN | ||||||||
| FirstName: | MODUPEOLA | ||||||||
| MiddleName: | OLADUNNI | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4960 S ALMA SCHOOL RD STE 18 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852485573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804474244 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4960 S ALMA SCHOOL RD STE 18 | ||||||||
| Address2: | |||||||||
| City: | CHANDLER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852485573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804474244 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2011 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 59420 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 023024100 | 05 | FL | MEDICAID |