Healthcare Provider Details

I. General information

NPI: 1609160308
Provider Name (Legal Business Name): ADEOLU OLASUNKANMI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2011
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2331 FRANKLIN RD SW
ROANOKE VA
24014
US

IV. Provider business mailing address

2331 FRANKLIN RD SW
ROANOKE VA
24014-1111
US

V. Phone/Fax

Practice location:
  • Phone: 540-224-5170
  • Fax: 540-344-3016
Mailing address:
  • Phone: 540-224-5170
  • Fax: 540-344-3016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number174579
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number0101264771
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: