Healthcare Provider Details

I. General information

NPI: 1205217965
Provider Name (Legal Business Name): ADETOKUNBO OBAYEMI JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ADE OBAYEMI JR. MD

II. Dates (important events)

Enumeration Date: 06/17/2015
Last Update Date: 03/24/2023
Certification Date: 03/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 EAST ADAMS STREET CWB RM 251
SYRACUSE NY
13210
US

IV. Provider business mailing address

750 E ADAMS ST
SYRACUSE NY
13210-2342
US

V. Phone/Fax

Practice location:
  • Phone: 201-431-5751
  • Fax:
Mailing address:
  • Phone: 315-464-7279
  • Fax: 315-464-7282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number308888
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number308888
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number308888
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: