Basic Information
| Provider Information | |||||||||
| NPI: | 1487747069 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | OLUWASEGUN | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | MOPELOLA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 592 ROCKAWAY AVE | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112125539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
| FaxNumber: | 7183455794 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 ASHFORD ST | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183455000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 07/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 018744-1 | NY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 04501539 | 05 | NY | MEDICAID |