Healthcare Provider Details

I. General information

NPI: 1497733810
Provider Name (Legal Business Name): OLADIPO A ADENIYI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 01/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 REDROCK DR
GALLUP NM
87301-5655
US

IV. Provider business mailing address

1801 REDROCK DR
GALLUP NM
87301-5655
US

V. Phone/Fax

Practice location:
  • Phone: 505-863-7993
  • Fax: 505-863-9406
Mailing address:
  • Phone: 505-863-7993
  • Fax: 505-863-9406

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number2002-0397
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: