Basic Information
| Provider Information | |||||||||
| NPI: | 1285819821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADEWUNMI | ||||||||
| FirstName: | ADESHOLA | ||||||||
| MiddleName: | KAZEEM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | BOX 111 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707937750 | ||||||||
| FaxNumber: | 7707937755 | ||||||||
| Practice Location | |||||||||
| Address1: | 677 CHURCH ST NE | ||||||||
| Address2: | BOX 111 | ||||||||
| City: | MARIETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300601101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7707937750 | ||||||||
| FaxNumber: | 7707937755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 01/28/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 064735 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 064735 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist | 208100000X | 303015 | LA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 363346743B | 05 | GA | MEDICAID | 363346743A | 05 | GA | MEDICAID |