Provider Demographics
NPI:1316467012
Name:MAFOLASIRE, ABIODUN
Entity type:Individual
Prefix:
First Name:ABIODUN
Middle Name:
Last Name:MAFOLASIRE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 FRANCIS ST STE 9B
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02215-5501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 FRANCIS ST STE 9B
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02215-5501
Practice Address - Country:US
Practice Address - Phone:617-632-9236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-23
Last Update Date:2017-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA272660208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery