Healthcare Provider Details

I. General information

NPI: 1346105384
Provider Name (Legal Business Name): KOLAWOLE ABIMBOLA ADEAGBO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2025
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4660 MARTIN LUTHER KING JR AVE SW STE A2
WASHINGTON DC
20032-4933
US

IV. Provider business mailing address

9889 GOOD LUCK RD APT 2
LANHAM MD
20706-3238
US

V. Phone/Fax

Practice location:
  • Phone: 202-318-0179
  • Fax:
Mailing address:
  • Phone: 313-290-9446
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: