Healthcare Provider Details

I. General information

NPI: 1811296668
Provider Name (Legal Business Name): BOLANLE ADEOLA ADEPOJU M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2011
Last Update Date: 08/08/2023
Certification Date: 08/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

IV. Provider business mailing address

200 HIGH PARK AVE
GOSHEN IN
46526-4810
US

V. Phone/Fax

Practice location:
  • Phone: 574-364-2888
  • Fax:
Mailing address:
  • Phone: 574-364-2888
  • Fax: 574-364-2590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number01073993
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01073993
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: