Healthcare Provider Details

I. General information

NPI: 1184937518
Provider Name (Legal Business Name): ADETOKUNBO OLUWASANJO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2010
Last Update Date: 12/24/2020
Certification Date: 12/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

795 STATE ROAD 47
LAKE CITY FL
32025-0453
US

IV. Provider business mailing address

4371 VERONICA S SHOEMAKER BLVD
FORT MYERS FL
33916-2216
US

V. Phone/Fax

Practice location:
  • Phone: 386-401-7066
  • Fax: 833-933-0709
Mailing address:
  • Phone: 239-274-8200
  • Fax: 239-278-3350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberME141781
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD449227
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT196670
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberME141781
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME141781
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License NumberME141781
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: