Healthcare Provider Details

I. General information

NPI: 1548812415
Provider Name (Legal Business Name): AANUOLUWAPO OBISESAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2019
Last Update Date: 07/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 LEHIGH ST
EASTON PA
18042-3860
US

IV. Provider business mailing address

2040 LEHIGH ST
EASTON PA
18042-3860
US

V. Phone/Fax

Practice location:
  • Phone: 484-542-6367
  • Fax:
Mailing address:
  • Phone: 484-542-6367
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMT218869
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: