Basic Information
| Provider Information | |||||||||
| NPI: | 1104011766 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BANKOLE | ||||||||
| FirstName: | ADEGBENGA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 RIVERS CIRCLE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245170 | ||||||||
| FaxNumber: | 5409838229 | ||||||||
| Practice Location | |||||||||
| Address1: | 3 RIVERS CIRCLE | ||||||||
| Address2: | SUITE 302 | ||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245170 | ||||||||
| FaxNumber: | 5409838229 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RR0500X | 010245177 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
ID Information
| ID | Type | State | Issuer | Description | 3810014657 | 05 | WV | MEDICAID | 540506332004 | 01 | VA | TRICARE | OTHER |