Provider Demographics
NPI:1659462893
Name:AGBOOLA, MODUPEOLA MOTOMORI (DPT)
Entity type:Individual
Prefix:MISS
First Name:MODUPEOLA
Middle Name:MOTOMORI
Last Name:AGBOOLA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5717 COUNTRY VIEW LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75034-4637
Mailing Address - Country:US
Mailing Address - Phone:214-470-1899
Mailing Address - Fax:214-469-2717
Practice Address - Street 1:5717 COUNTRY VIEW LN
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75034-4637
Practice Address - Country:US
Practice Address - Phone:214-470-1899
Practice Address - Fax:214-469-2717
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2008-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL19515225100000X
NJ40QA00933200225100000X
TX1170710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist