Provider Demographics
NPI:1528443033
Name:AGUNBIADE, MODUPE (DPM)
Entity type:Individual
Prefix:DR
First Name:MODUPE
Middle Name:
Last Name:AGUNBIADE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:310 CENTRAL AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2838
Mailing Address - Country:US
Mailing Address - Phone:973-337-2893
Mailing Address - Fax:201-228-1689
Practice Address - Street 1:310 CENTRAL AVE STE 303
Practice Address - Street 2:
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2838
Practice Address - Country:US
Practice Address - Phone:973-337-2893
Practice Address - Fax:201-228-1689
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-26
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00340500213ES0103X
PASC006448213ES0103X
NY006878213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty