Healthcare Provider Details

I. General information

NPI: 1669544169
Provider Name (Legal Business Name): ABIDEMI ADETOYESE ADEGBOLA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 06/17/2021
Certification Date: 06/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3905 FORD RD SUITE 6
PHILADELPHIA PA
19131-2824
US

IV. Provider business mailing address

834 CHESTNUT ST PH113
PHILADELPHIA PA
19107-5127
US

V. Phone/Fax

Practice location:
  • Phone: 215-220-2196
  • Fax:
Mailing address:
  • Phone: 314-348-4546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207SG0201X
TaxonomyClinical Genetics (M.D.) Physician
License Number227766
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number13062
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number13062
License Number StateNH
# 4
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD446583
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: