Healthcare Provider Details

I. General information

NPI: 1851611123
Provider Name (Legal Business Name): ADETOLA FADEYIBI LOUIS-JACQUES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2010
Last Update Date: 07/12/2021
Certification Date: 07/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3603
US

IV. Provider business mailing address

PO BOX 100294
GAINESVILLE FL
32610-0294
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-7584
  • Fax:
Mailing address:
  • Phone: 352-273-7584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME132996
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMT198091
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License NumberME132996
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: