Provider Demographics
NPI:1174935209
Name:ABIMBOYE, MOYOSORE OMOWUMI (MD)
Entity type:Individual
Prefix:MS
First Name:MOYOSORE
Middle Name:OMOWUMI
Last Name:ABIMBOYE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 YORK ST
Mailing Address - Street 2:YNHH GERIATRIC MEDICINE
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-3220
Mailing Address - Country:US
Mailing Address - Phone:203-688-4242
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:YNHH GERIATRIC MEDICINE
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:208-520-3688
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-23
Last Update Date:2022-07-21
Deactivation Date:2014-12-26
Deactivation Code:
Reactivation Date:2015-04-08
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT56875207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program