Basic Information
| Provider Information | |||||||||
| NPI: | 1114360666 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADASOFUNJO | ||||||||
| FirstName: | OLUWABUKOLA | ||||||||
| MiddleName: | PRINCESS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ALO | ||||||||
| OtherFirstName: | OLUWABUKOLA | ||||||||
| OtherMiddleName: | PRINCESS | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 30 PROSPECT AVE | ||||||||
| Address2: | |||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076011915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519964450 | ||||||||
| FaxNumber: | 5519965729 | ||||||||
| Practice Location | |||||||||
| Address1: | 87 RTE 17 N | ||||||||
| Address2: | STE 118 | ||||||||
| City: | MAYWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 07607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5519964450 | ||||||||
| FaxNumber: | 5519965729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/15/2013 | ||||||||
| LastUpdateDate: | 08/09/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 25MA11118600 | NJ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry |
No ID Information.