Healthcare Provider Details

I. General information

NPI: 1457932014
Provider Name (Legal Business Name): MOFESOLA MODUPE DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 E CHESTNUT ST STE 310
AUGUSTA ME
04330-5760
US

IV. Provider business mailing address

530 NE GLEN OAK AVE
PEORIA IL
61637-0001
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-2977
  • Fax: 207-626-9374
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberDO4361
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: