Healthcare Provider Details

I. General information

NPI: 1881441103
Provider Name (Legal Business Name): ISAAC TOLULOPE ABULATAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

IV. Provider business mailing address

11800 E 12 MILE RD
WARREN MI
48093-3472
US

V. Phone/Fax

Practice location:
  • Phone: 586-573-5059
  • Fax:
Mailing address:
  • Phone: 586-573-5059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number4351052963
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: