1114360666 NPI number — DR. OLUWABUKOLA PRINCESS ADASOFUNJO M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114360666 NPI number — DR. OLUWABUKOLA PRINCESS ADASOFUNJO M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ADASOFUNJO
Provider First Name:
OLUWABUKOLA
Provider Middle Name:
PRINCESS
Provider Name Prefix Text:
DR.
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:
ALO
Provider Other First Name:
OLUWABUKOLA
Provider Other Middle Name:
PRINCESS
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114360666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
FORT HEALTH
Provider Second Line Business Mailing Address:
613 WASHINGTON BLVD
Provider Business Mailing Address City Name:
JERSEY CITY
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
201-208-2616
Provider Business Mailing Address Fax Number:
973-250-4028

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
87 RTE 17 N
Provider Second Line Business Practice Location Address:
STE 118
Provider Business Practice Location Address City Name:
MAYWOOD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
551-996-4450
Provider Business Practice Location Address Fax Number:
551-996-5729
Provider Enumeration Date:
04/15/2013

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: 2084P0804X , with the licence number:  25MA11118600 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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