Basic Information
| Provider Information | |||||||||
| NPI: | 1629206743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | UKABI | ||||||||
| FirstName: | MOJISOLA | ||||||||
| MiddleName: | GLADYS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | UKABI | ||||||||
| OtherFirstName: | MOJISOLA | ||||||||
| OtherMiddleName: | GLADYS | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 8 AVALON WAY | ||||||||
| Address2: | |||||||||
| City: | SANDY HOOK | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064821661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7132132955 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 401 FEDERAL RD | ||||||||
| Address2: | |||||||||
| City: | BROOKFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068042037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037756365 | ||||||||
| FaxNumber: | 2037403010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2009 | ||||||||
| LastUpdateDate: | 10/31/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 62160 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.