Basic Information
| Provider Information | |||||||||
| NPI: | 1912919044 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | AJIBULU | ||||||||
| FirstName: | ADETOKUNBO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 374 STOCKHOLM ST | ||||||||
| Address2: | C/O FACULTY PRACTICE MANAGEMENT SUITE I-37 NORTH | ||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112374006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189636551 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11949 UNION TPKE | ||||||||
| Address2: | APT # 5D | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113756151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6463216197 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 02/01/2008 | ||||||||
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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 | 363A00000X | 010505 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | VA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.