Healthcare Provider Details

I. General information

NPI: 1124281233
Provider Name (Legal Business Name): SAMUEL BABATUNDE ADEGBOYEGA DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2008
Last Update Date: 11/03/2020
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 CENTRAL AVE STE 102
EAST ORANGE NJ
07018-2838
US

IV. Provider business mailing address

83 ABERDEEN RD
MATAWAN NJ
07747-2720
US

V. Phone/Fax

Practice location:
  • Phone: 973-207-1678
  • Fax: 732-862-1242
Mailing address:
  • Phone: 973-207-1678
  • Fax: 732-862-1242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006368
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00306200
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: