Healthcare Provider Details

I. General information

NPI: 1386176139
Provider Name (Legal Business Name): ADEBUSOLA ADESINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

975 SERENO DR RM H3351
VALLEJO CA
94589-2441
US

IV. Provider business mailing address

1601 TRINITY ST
AUSTIN TX
78712-1765
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-2737
  • Fax:
Mailing address:
  • Phone: 833-882-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberT1625
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA163027
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: