=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205152139
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADEGBENGA A ADETOLA M D INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/16/2010
-----------------------------------------------------
Last Update Date | 12/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3737 MARTIN LUTHER KING JR BLVD STE 400
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-631-2838
-----------------------------------------------------
Fax | 310-632-4701
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3737 MARTIN LUTHER KING JR BLVD STE 400
-----------------------------------------------------
City | LYNWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90262-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-631-2838
-----------------------------------------------------
Fax | 310-632-4701
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DOCTOR
-----------------------------------------------------
Name | ADETOLA ADEGBENGA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 310-631-2838
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------