Basic Information
| Provider Information | |||||||||
| NPI: | 1952614851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ADELOLA | ||||||||
| FirstName: | OLUBUKOLA | ||||||||
| MiddleName: | ABIGAIL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1002 S KNOXVILLE AVE | ||||||||
| Address2: | |||||||||
| City: | SAINT MARYS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458852607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4193943387 | ||||||||
| FaxNumber: | 4193949575 | ||||||||
| Practice Location | |||||||||
| Address1: | 4463 STATE ROUTE 66 | ||||||||
| Address2: | |||||||||
| City: | MINSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 458658727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4196283821 | ||||||||
| FaxNumber: | 4196289501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 08/05/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 35.099923 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0079745 | 05 | OH | MEDICAID | H173472 | 01 | OH | MEDICARE PTAN | OTHER |