MEDICARE: DR. ADERONKE ADEFISAYO 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
1	208000000X	Pediatrics Physician	26085	MS
2	208000000X	Pediatrics Physician	T7472	TX

General Provider Information

NPI Number	:	1770842130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ADERONKE ADEFISAYO M.D

Provider Business Mailing Address
First Line	:	7231 LAGUNA VILLAS
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77036-4394
Country	:	US
Telephone Number	:	631-346-5387
Fax Number	:	662-627-5440

Provider Business Practice Location Address
First Line	:	7231 LAGUNA VILLAS
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77036-4394
Country	:	US
Telephone Number	:	631-344-5387
Fax Number	:	662-627-5440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2012
Last Update Date	:	06/27/2023

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