Basic Information
| Provider Information | |||||||||
| NPI: | 1649421934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADEYEKUN | ||||||||
| FirstName: | OMOBOLANLE | ||||||||
| MiddleName: | OMOLAYO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ONIBONOJE | ||||||||
| OtherFirstName: | OMOBOLANLE | ||||||||
| OtherMiddleName: | OMOLAYO | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 39 EUCLID AVE | ||||||||
| Address2: | #2A | ||||||||
| City: | HACKENSACK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076014565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5169416230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2620 N. WESTWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737272640 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2008 | ||||||||
| LastUpdateDate: | 01/18/2012 | ||||||||
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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 | 207R00000X | 2010021661 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1649421934 | 05 | MO | MEDICAID |