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General NPI Number Information
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NPI Number | 1770033276
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Entity Type | Organization
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Legal Business Name | MOGBONJUBOLA A ADEYEMO MD PROFESSIONAL MEDICAL CORPORATION
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Dates
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Enumeration Date | 10/07/2016
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Last Update Date | 10/07/2016
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Provider Practice Location Address
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Address Line | 361 N SAN JACINTO ST SUITE A B C
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City | HEMET
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State | CA
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Zip | 92543-3118
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Country | US
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Telephone | 951-492-0728
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Fax |
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Provider Business Mailing Address
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Address Line | 361 N SAN JACINTO ST SUITE A B C
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City | HEMET
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State | CA
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Zip | 92543-3118
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Country | US
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Telephone | 951-492-0728
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Fax |
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Authorized Official
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Title or Position | CREDENTIALING MANAGER
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Name | MARITA WAGNER
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Credential |
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Telephone | 951-369-9853
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | A85970
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License Number State | CA
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