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NPI Code Detail

MEDICARE: ABIDEMI ADETOYESE ADEGBOLA M.D

MEDICARE: ABIDEMI ADETOYESE ADEGBOLA M.D
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1207SG0201XClinical Genetics (M.D.) Physician227766MA
22084P0800XPsychiatry Physician13062NH
32084P0804XChild & Adolescent Psychiatry Physician13062NH
42084P0800XPsychiatry PhysicianMD446583PA

General Provider Information

NPI Number : 1669544169
Entity Type Code : Individual
Provider Name (Legal Business Name) : ABIDEMI ADETOYESE ADEGBOLA M.D
Provider Business Mailing Address
First Line : 834 CHESTNUT ST
Second Line : PH113
City : PHILADELPHIA
State : PA
Zip : 19107-5127
Country : US
Telephone Number : 314-348-4546
Fax Number :
Provider Business Practice Location Address
First Line : 3905 FORD RD
Second Line : SUITE 6
City : PHILADELPHIA
State : PA
Zip : 19131-2824
Country : US
Telephone Number : 215-220-2196
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/14/2006
Last Update Date : 06/17/2021

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