Healthcare Provider Details

I. General information

NPI: 1245838473
Provider Name (Legal Business Name): AFEEZ KOLAWOLE ADISA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2020
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 37TH AVE SW
MINOT ND
58701-7669
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 701-418-8860
  • Fax:
Mailing address:
  • Phone: 701-857-3517
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number21756
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number21756
License Number StateND
# 3
Primary TaxonomyN
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number57.248734
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: