Healthcare Provider Details

I. General information

NPI: 1639631864
Provider Name (Legal Business Name): BABATUNDE K OLUWASEUN ADEYEMI DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2019
Last Update Date: 10/07/2021
Certification Date: 10/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 N STATE ST
JACKSON MS
39216-4500
US

IV. Provider business mailing address

1223 WATERVIEW ST
FAR ROCKAWAY NY
11691-1742
US

V. Phone/Fax

Practice location:
  • Phone: 601-984-5582
  • Fax:
Mailing address:
  • Phone: 718-737-5109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number28791
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: