Basic Information
| Provider Information | |||||||||
| NPI: | 1114313590 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADEDIPE | ||||||||
| FirstName: | ADEFUNKE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 578 N LEAVITT RD | ||||||||
| Address2: | |||||||||
| City: | AMHERST | ||||||||
| State: | OH | ||||||||
| PostalCode: | 440011131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409881009 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3600 KOLBE RD STE 227 | ||||||||
| Address2: | |||||||||
| City: | LORAIN | ||||||||
| State: | OH | ||||||||
| PostalCode: | 44053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4409603304 | ||||||||
| FaxNumber: | 4409604733 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2015 | ||||||||
| LastUpdateDate: | 11/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.133536 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0301107 | 05 | OH | MEDICAID |