Basic Information
| Provider Information | |||||||||
| NPI: | 1902178825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AKINBOLA | ||||||||
| FirstName: | MICHAEL | ||||||||
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| Credential: | PT, DPT, CSCS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 63 E DELAWARE AVE | ||||||||
| Address2: | 053 MCKINLY LAB | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197163798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028318893 | ||||||||
| FaxNumber: | 3028314468 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 E DELAWARE AVE | ||||||||
| Address2: | 053 MCKINLY LAB | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197163798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3028318893 | ||||||||
| FaxNumber: | 3028314468 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2012 | ||||||||
| LastUpdateDate: | 02/08/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0002821 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | J1-0002821 | 01 | DE | DELAWARE DEPARTMENT OF STATE PT LICENSE | OTHER |