Healthcare Provider Details

I. General information

NPI: 1467533661
Provider Name (Legal Business Name): ADEYINKA A ADEWALE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 09/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 GODFREY RD
GODFREY IL
62035-2558
US

IV. Provider business mailing address

3300 GODFREY RD
GODFREY IL
62035-2558
US

V. Phone/Fax

Practice location:
  • Phone: 618-466-8787
  • Fax: 618-466-4703
Mailing address:
  • Phone: 618-466-8787
  • Fax: 618-466-4703

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046009191
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: