Healthcare Provider Details

I. General information

NPI: 1033225248
Provider Name (Legal Business Name): ADEKUNLE GBADEGESIN KUKU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 04/09/2021
Certification Date: 04/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US HWY 491 NORTH
SHIPROCK NM
87420
US

IV. Provider business mailing address

PO BOX 160
SHIPROCK NM
87420-0160
US

V. Phone/Fax

Practice location:
  • Phone: 505-368-6401
  • Fax: 505-368-6431
Mailing address:
  • Phone: 505-368-6401
  • Fax: 505-368-6431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number01062251A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: