Basic Information
| Provider Information | |||||||||
| NPI: | 1386693190 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GBADAMOSI | ||||||||
| FirstName: | FATAI | ||||||||
| MiddleName: | ADESINA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 206 S ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142012398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168470328 | ||||||||
| FaxNumber: | 7168472715 | ||||||||
| Practice Location | |||||||||
| Address1: | 206 S ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142012398 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7168470328 | ||||||||
| FaxNumber: | 7168472715 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 12/09/2011 | ||||||||
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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 | 207R00000X | 248561 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02050035 | 05 | NY | MEDICAID | 0410964 | 01 | NY | INDEPENDENT HEALTH | OTHER | 00025064402 | 01 | NY | UNIVERA | OTHER | 000525978004 | 01 | NY | BLUE CROSS & BLUE SHIELD | OTHER |