Healthcare Provider Details

I. General information

NPI: 1346265808
Provider Name (Legal Business Name): OLUREMI C ADESIDA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 04/21/2021
Certification Date: 04/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11115 PARKVIEW PLAZA DR
FORT WAYNE IN
46845-1701
US

IV. Provider business mailing address

1234 E DUPONT RD SUITE 1
FORT WAYNE IN
46825-1545
US

V. Phone/Fax

Practice location:
  • Phone: 260-373-9965
  • Fax: 260-458-5664
Mailing address:
  • Phone: 260-373-9700
  • Fax: 260-373-9740

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01068108A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-116960
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number01068108A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number036-116960
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: