Healthcare Provider Details

I. General information

NPI: 1457711277
Provider Name (Legal Business Name): AGBOADE ADEMIJU
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2016
Last Update Date: 03/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 INTERVALE AVE, ARCHCARE, BRONX
BRONX NY
10459
US

IV. Provider business mailing address

872 MACON ST APT 4R
BROOKLYN NY
11233-1673
US

V. Phone/Fax

Practice location:
  • Phone: 718-732-7171
  • Fax:
Mailing address:
  • Phone: 234-307-3192
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number595738
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: