Healthcare Provider Details

I. General information

NPI: 1356791644
Provider Name (Legal Business Name): KOLADE MUCHAILI AGBOOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 01/07/2026
Certification Date: 01/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS ST
BOSTON MA
02115-6110
US

IV. Provider business mailing address

75 FRANCIS ST
BOSTON MA
02115-6110
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 617-732-5500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number292970
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License Number2024-01238
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2024-01238
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: