Healthcare Provider Details

I. General information

NPI: 1952301681
Provider Name (Legal Business Name): GBOLAGADE O BABALOLA DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 01/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 LAKE ST
NEWBURGH NY
12550-5263
US

IV. Provider business mailing address

2570 ROUTE 9W STE 10
CORNWALL NY
12518-1370
US

V. Phone/Fax

Practice location:
  • Phone: 845-563-8000
  • Fax: 845-565-1364
Mailing address:
  • Phone: 845-220-3100
  • Fax: 845-534-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MB08334000
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number296706
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: