Basic Information
Provider Information | |||||||||
NPI: | 1720291339 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AWONUGA | ||||||||
FirstName: | MODUPE | ||||||||
MiddleName: | TEMIDAYO | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.B.B.S | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | KUYEBI | ||||||||
OtherFirstName: | MODUPE | ||||||||
OtherMiddleName: | TEMIDAYO | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.B.B.S | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 804 SERVICE RD | ||||||||
Address2: | A201 | ||||||||
City: | EAST LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 488247015 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5178842976 | ||||||||
FaxNumber: | 5174323928 | ||||||||
Practice Location | |||||||||
Address1: | 1215 E MICHIGAN AVE | ||||||||
Address2: | SPARROW HOSPITAL - NEONATOLOGY | ||||||||
City: | LANSING | ||||||||
State: | MI | ||||||||
PostalCode: | 489121811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5173642188 | ||||||||
FaxNumber: | 5173643994 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2007 | ||||||||
LastUpdateDate: | 07/12/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080N0001X | 055407 | GA | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine | 2080N0001X | 4301089600 | MI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Neonatal-Perinatal Medicine |
ID Information
ID | Type | State | Issuer | Description | 1720291339 | 05 | MI |   | MEDICAID |