Healthcare Provider Details

I. General information

NPI: 1558196550
Provider Name (Legal Business Name): ADEWALE KABIR ADEGBENRO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2024
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7785 N STATE ST
LOWVILLE NY
13367-1229
US

IV. Provider business mailing address

6417 PHANTOM MOON WALK
CLARKSVILLE MD
21029-1283
US

V. Phone/Fax

Practice location:
  • Phone: 315-376-9626
  • Fax: 315-376-5444
Mailing address:
  • Phone: 804-624-0360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number332697
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number86144
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: