Healthcare Provider Details

I. General information

NPI: 1003639121
Provider Name (Legal Business Name): CANDACE A ADEDOKUN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2021
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date: 11/05/2024
Reactivation Date: 11/06/2024

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
WRIGHT PAT OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-257-9926
  • Fax:
Mailing address:
  • Phone: 937-257-9926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2023021151
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2023021151
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: