Healthcare Provider Details

I. General information

NPI: 1962795658
Provider Name (Legal Business Name): KOLAWOLE JEGEDE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2011
Last Update Date: 04/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6740 4TH AVE
BROOKLYN NY
11220-5350
US

IV. Provider business mailing address

6740 4TH AVE
BROOKLYN NY
11220-5350
US

V. Phone/Fax

Practice location:
  • Phone: 929-455-2000
  • Fax:
Mailing address:
  • Phone: 929-455-2000
  • Fax: 929-455-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number290224
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: