1417118159 NPI number — IBIRONKE VIVIAN ADELAJA M.D.

Table of content: IBIRONKE VIVIAN ADELAJA M.D. (NPI 1417118159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417118159 NPI number — IBIRONKE VIVIAN ADELAJA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADELAJA
Provider First Name:
IBIRONKE
Provider Middle Name:
VIVIAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417118159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/04/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2625 E DIVISADERO ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FRESNO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93721-1431
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
559-443-2682
Provider Business Mailing Address Fax Number:
559-443-2681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2335 E KASHIAN LN STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93701-2211
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-256-5140
Provider Business Practice Location Address Fax Number:
559-485-4505
Provider Enumeration Date:
06/24/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  A102787 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)