Healthcare Provider Details

I. General information

NPI: 1922467620
Provider Name (Legal Business Name): KUPONIYI FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2016
Last Update Date: 02/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

199 NEW RD SUITE 61-398
LINWOOD NJ
08221-2025
US

IV. Provider business mailing address

199 NEW RD SUITE 61-398
LINWOOD NJ
08221-2025
US

V. Phone/Fax

Practice location:
  • Phone: 609-534-5859
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MOJISOLA DABNEY
Title or Position: CEO
Credential:
Phone: 609-534-5859