Healthcare Provider Details

I. General information

NPI: 1497000103
Provider Name (Legal Business Name): ADEBOLA ADELEKE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2012
Last Update Date: 04/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 SAYBROOK RD STE 100
MIDDLETOWN CT
06457-4788
US

IV. Provider business mailing address

512 SAYBROOK RD STE 100
MIDDLETOWN CT
06457-4788
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-7636
  • Fax: 860-894-1882
Mailing address:
  • Phone: 860-347-7636
  • Fax: 860-894-1882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number945
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number945
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number945
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: