Basic Information
Provider Information | |||||||||
NPI: | 1003115387 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AGUNBIADE | ||||||||
FirstName: | TOLULOPE | ||||||||
MiddleName: | ADESIYUN | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ADESIYUN | ||||||||
OtherFirstName: | TOLULOPE | ||||||||
OtherMiddleName: | ADEBISI | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 301 LIPPINCOTT DR STE 410 | ||||||||
Address2: |   | ||||||||
City: | MARLTON | ||||||||
State: | NJ | ||||||||
PostalCode: | 080534197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8563550340 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1 BRACE RD STE C2 | ||||||||
Address2: |   | ||||||||
City: | CHERRY HILL | ||||||||
State: | NJ | ||||||||
PostalCode: | 080342600 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8564828900 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/25/2011 | ||||||||
LastUpdateDate: | 08/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RA0001X | FA5309504 | MD | N |   |   |   |   | 207RC0000X | FA5309504 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RA0001X | 25MA11567700 | NJ | Y |   |   |   |   |
No ID Information.