Healthcare Provider Details

I. General information

NPI: 1528124039
Provider Name (Legal Business Name): ADEKUNLE MOJEED OWOLABI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2006
Last Update Date: 08/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

489 STATE ST EMIC KELLEY 6
BANGOR ME
04401-6616
US

IV. Provider business mailing address

43 WHITING HILL RD STE 300
BREWER ME
04412-1006
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7000
  • Fax: 207-973-4441
Mailing address:
  • Phone: 207-973-5035
  • Fax: 207-973-5042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number018208
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: