Healthcare Provider Details

I. General information

NPI: 1760829873
Provider Name (Legal Business Name): BOLANLE MARIAM GBADAMOSI M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: BOLANLE MARIAM SHODEINDE

II. Dates (important events)

Enumeration Date: 05/30/2013
Last Update Date: 06/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2711 X RAY DR STE 3701
GASTONIA NC
28054-7491
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 980-834-9600
  • Fax: 980-834-9605
Mailing address:
  • Phone: 704-834-2450
  • Fax: 704-671-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number0101266137
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number2019-01346
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: