Healthcare Provider Details

I. General information

NPI: 1295958445
Provider Name (Legal Business Name): ABIOLA FAMILUSI
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 08/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 BEACH 20TH ST
FAR ROCKAWAY NY
11691-3645
US

IV. Provider business mailing address

529 BEACH 20TH ST
FAR ROCKAWAY NY
11691-3645
US

V. Phone/Fax

Practice location:
  • Phone: 718-327-7307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State

VIII. Authorized Official

Name: ABIOLA FAMILUSI
Title or Position: PRESIDENT
Credential: M.D.
Phone: 347-256-1956