Healthcare Provider Details

I. General information

NPI: 1891360525
Provider Name (Legal Business Name): MODUPEOLUWA OWOLABI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 E APPLE ST STE 6221
DAYTON OH
45409-2939
US

IV. Provider business mailing address

3170 KETTERING BLVD BLDG B2ND
MORAINE OH
45439-1924
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-6630
  • Fax: 937-208-6641
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number331026-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: