Healthcare Provider Details

I. General information

NPI: 1437655891
Provider Name (Legal Business Name): JENNIFER OLUYEMISI ADEGHATE MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2018
Last Update Date: 10/01/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 N 87TH ST
MILWAUKEE WI
53226-4812
US

IV. Provider business mailing address

925 N 87TH ST FL 4
MILWAUKEE WI
53226-4812
US

V. Phone/Fax

Practice location:
  • Phone: 414-955-2020
  • Fax:
Mailing address:
  • Phone: 414-955-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0107X
TaxonomyRetina Specialist (Ophthalmology) Physician
License Number83991-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number317267
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: